Provider Demographics
NPI: | 1477955128 |
---|---|
Name: | COUNTY OF SAN LUIS OBISPO |
Entity Type: | Organization |
Organization Name: | COUNTY OF SAN LUIS OBISPO |
Other - Org Name: | SHELL BEACH ELEMENTARY SCHOOL |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | MEDICAL DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | M DAISY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ILANO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 805-781-4700 |
Mailing Address - Street 1: | 2178 JOHNSON AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN LUIS OBISPO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 93401-4535 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2100 SHELL BEACH RD |
Practice Address - Street 2: | |
Practice Address - City: | SHELL BEACH |
Practice Address - State: | CA |
Practice Address - Zip Code: | 93449-1800 |
Practice Address - Country: | US |
Practice Address - Phone: | 805-781-4700 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-09-24 |
Last Update Date: | 2014-09-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | CP065A | Medicare PIN |