Provider Demographics
NPI:1487858817
Name:BRISCOE, COY
Entity Type:Individual
Prefix:
First Name:COY
Middle Name:
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 VELA WAY
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1833
Mailing Address - Country:US
Mailing Address - Phone:805-717-1055
Mailing Address - Fax:
Practice Address - Street 1:240 E HIGHWAY 246
Practice Address - Street 2:SUITE 300
Practice Address - City:BUELLTON
Practice Address - State:CA
Practice Address - Zip Code:93427-9645
Practice Address - Country:US
Practice Address - Phone:805-688-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP09535146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic