Provider Demographics
NPI:1134173859
Name:CENTRAL COAST FAMILY CARE MEDICAL ASSOCIATES, INC
Entity type:Organization
Organization Name:CENTRAL COAST FAMILY CARE MEDICAL ASSOCIATES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-349-1227
Mailing Address - Street 1:220 S PALISADE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5931
Mailing Address - Country:US
Mailing Address - Phone:805-925-5334
Mailing Address - Fax:805-922-5923
Practice Address - Street 1:821 E CHAPEL ST STE 203
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4619
Practice Address - Country:US
Practice Address - Phone:805-925-5334
Practice Address - Fax:805-922-5923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ55899ZOtherBLUESHIELD
CAW14182Medicare PIN