Provider Demographics
NPI:1679736987
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:COMMUNITY HEALTH CENTERS, SANTA MARIA 3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
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 1:1414 S MILLER ST
Practice Address - Street 2:SUITE 9
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6923
Practice Address - Country:US
Practice Address - Phone:805-934-5400
Practice Address - Fax:805-938-9207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70477FOtherHEALTHY FAMILIES
CAFHC70477FMedicaid
CAW1508OtherMEDICARE