Provider Demographics
NPI:1558540740
Name:COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.
Other - Org Name:COMM HLTH CTRS NORTH COUNTY PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:CASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-929-3211
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:500 FIRST ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3742
Practice Address - Country:US
Practice Address - Phone:805-239-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548462310Medicaid
CAFHC71030FMedicaid
CA1841217866Medicaid