Provider Demographics
NPI:1710919303
Name:CENTRAL COAST CLINICAL LABORATORY, INC
Entity Type:Organization
Organization Name:CENTRAL COAST CLINICAL LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MTASCP
Authorized Official - Phone:805-434-9080
Mailing Address - Street 1:350 POSADA LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-4059
Mailing Address - Country:US
Mailing Address - Phone:805-434-9080
Mailing Address - Fax:805-434-9082
Practice Address - Street 1:350 POSADA LN
Practice Address - Street 2:SUITE 100
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4059
Practice Address - Country:US
Practice Address - Phone:805-434-9080
Practice Address - Fax:805-434-9082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF11785291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
05D1012891OtherMEDICARE - OTHER
CACLF11785OtherDHS CLINICAL LAB LICENSE
05D1012891Medicare Oscar/Certification
05D1012891Medicare PIN