Provider Demographics
NPI:1477906451
Name:CENTRAL COAST SPEECH PATHOLOGY AND OROFACIAL MYOLOGY
Entity Type:Organization
Organization Name:CENTRAL COAST SPEECH PATHOLOGY AND OROFACIAL MYOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:805-441-1055
Mailing Address - Street 1:210 TRAFFIC WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3368
Mailing Address - Country:US
Mailing Address - Phone:805-441-1055
Mailing Address - Fax:805-904-6133
Practice Address - Street 1:210 TRAFFIC WAY
Practice Address - Street 2:SUITE C
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3368
Practice Address - Country:US
Practice Address - Phone:805-441-1055
Practice Address - Fax:805-904-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS96072261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1821083775OtherNPI