Provider Demographics
NPI:1649818626
Name:CENTRAL COAST REGENERATIVE MEDICINE INC
Entity type:Organization
Organization Name:CENTRAL COAST REGENERATIVE MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ELLEXIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-415-6549
Mailing Address - Street 1:628 CALIFORNIA BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2548
Mailing Address - Country:US
Mailing Address - Phone:805-540-2010
Mailing Address - Fax:
Practice Address - Street 1:628 CALIFORNIA BLVD STE E
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2548
Practice Address - Country:US
Practice Address - Phone:805-540-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2021-04-23
Deactivation Date:2021-02-09
Deactivation Code:
Reactivation Date:2021-04-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty