Provider Demographics
NPI:1912023870
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,MORRO BAY II
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
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:
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 1:760 MORRO BAY BLVD
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1918
Practice Address - Country:US
Practice Address - Phone:805-600-6001
Practice Address - Fax:805-600-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM71167FMedicaid