Provider Demographics
NPI:1508380031
Name:CENTRAL COAST EYE SURGERY, INC., A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CENTRAL COAST EYE SURGERY, INC., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAURITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-544-0006
Mailing Address - Street 1:941 CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2905
Mailing Address - Country:US
Mailing Address - Phone:805-544-0006
Mailing Address - Fax:
Practice Address - Street 1:941 CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-434-2350
Practice Address - Fax:805-434-9888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77319207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty