Provider Demographics
NPI:1578716759
Name:CENTRAL COAST RENAL CARE INC
Entity Type:Organization
Organization Name:CENTRAL COAST RENAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-548-8585
Mailing Address - Street 1:1551 BISHOP ST BLDG A STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4692
Mailing Address - Country:US
Mailing Address - Phone:805-548-8585
Mailing Address - Fax:805-548-8589
Practice Address - Street 1:1551 BISHOP ST BLDG A STE 110
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4692
Practice Address - Country:US
Practice Address - Phone:805-548-8585
Practice Address - Fax:805-548-8589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1221OtherSLO COUNTY MEDICAL SERVICES PROGRAM- GROUP PIN NUMBER
CAC3163787OtherSTATE CORPORATION NUMBER
CABV177AMedicare PIN