Provider Demographics
NPI:1629179205
Name:JOURNEY LITE OF THE CENTRAL COAST, LLC
Entity Type:Organization
Organization Name:JOURNEY LITE OF THE CENTRAL COAST, LLC
Other - Org Name:CONEJO SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:333 S MOORPARK RD
Mailing Address - Street 2:SUITE 339
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1008
Mailing Address - Country:US
Mailing Address - Phone:805-497-3690
Mailing Address - Fax:
Practice Address - Street 1:333 S MOORPARK RD
Practice Address - Street 2:SUITE 339
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1008
Practice Address - Country:US
Practice Address - Phone:805-497-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPPLIED FOR261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical