Provider Demographics
NPI:1518064948
Name:COUNTY OF SAN LUIS OBISPO
Entity Type:Organization
Organization Name:COUNTY OF SAN LUIS OBISPO
Other - Org Name:PUBLIC HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:P
Authorized Official - Last Name:LIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-781-4021
Mailing Address - Street 1:2191 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4534
Mailing Address - Country:US
Mailing Address - Phone:805-781-5519
Mailing Address - Fax:805-781-1048
Practice Address - Street 1:2191 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4534
Practice Address - Country:US
Practice Address - Phone:805-781-5519
Practice Address - Fax:805-781-1048
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SAN LUIS OBISPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAG461382083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT11660FMedicaid
CAW10621Medicare ID - Type Unspecified