Provider Demographics
NPI:1962676775
Name:CENTRAL COAST OBSTETRICS & GYNECOLOGY, INC.
Entity Type:Organization
Organization Name:CENTRAL COAST OBSTETRICS & GYNECOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:LICKNESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-544-8811
Mailing Address - Street 1:100 CASA STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1893
Mailing Address - Country:US
Mailing Address - Phone:805-548-0775
Mailing Address - Fax:805-548-0777
Practice Address - Street 1:35 CASA STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1890
Practice Address - Country:US
Practice Address - Phone:805-548-0775
Practice Address - Fax:805-548-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0092003Medicaid
CAGR0092003Medicaid