Provider Demographics
NPI:1427382811
Name:CENTRAL COAST OTOLARYNGOLOGY
Entity Type:Organization
Organization Name:CENTRAL COAST OTOLARYNGOLOGY
Other - Org Name:SLEEP DISORDERS CENTER OF SANTA MARIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WIKHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-614-9250
Mailing Address - Street 1:116 S PALISADE DR
Mailing Address - Street 2:STE 206
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-8904
Mailing Address - Country:US
Mailing Address - Phone:805-614-9250
Mailing Address - Fax:805-614-9260
Practice Address - Street 1:116 S PALISADE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-8904
Practice Address - Country:US
Practice Address - Phone:805-614-9250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACL711AOtherMEDICARE PTAN