Provider Demographics
NPI:1831168772
Name:SAN LUIS PRIMARY CARE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SAN LUIS PRIMARY CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEECE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-546-0780
Mailing Address - Street 1:1941 JOHNSON AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4140
Mailing Address - Country:US
Mailing Address - Phone:805-546-0780
Mailing Address - Fax:805-546-0332
Practice Address - Street 1:1941 JOHNSON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4140
Practice Address - Country:US
Practice Address - Phone:805-546-0780
Practice Address - Fax:805-546-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2321370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00890ZOtherBLUE SHIELD OF CALIFORNIA
CAW15400Medicare ID - Type UnspecifiedMEDICARE GROUP ID #
CH6231Medicare PIN