Provider Demographics
NPI:1518207067
Name:AFFILIATED PATHOLOGISTS OF THE CENTRAL COAST
Entity Type:Organization
Organization Name:AFFILIATED PATHOLOGISTS OF THE CENTRAL COAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-710-7308
Mailing Address - Street 1:PO BOX 22405
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0405
Mailing Address - Country:US
Mailing Address - Phone:805-710-7308
Mailing Address - Fax:
Practice Address - Street 1:1911 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4131
Practice Address - Country:US
Practice Address - Phone:805-543-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZC0500X
CA05D0586788207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHC257AMedicare PIN