Provider Demographics
NPI:1780198523
Name:CENTRAL COAST PEDIATRIC SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:CENTRAL COAST PEDIATRIC SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:KANARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-420-0879
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92674-1359
Mailing Address - Country:US
Mailing Address - Phone:949-492-3514
Mailing Address - Fax:949-366-2390
Practice Address - Street 1:400 W PUEBLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4353
Practice Address - Country:US
Practice Address - Phone:805-879-4271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty