1326612193 NPI number — ATHENA MEDICAL GROUP OF THE CENTRAL COAST, INC.

Table of content: DR. JEANMARIE LIKAR SANDFORD PSY.D. (NPI 1811310881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326612193 NPI number — ATHENA MEDICAL GROUP OF THE CENTRAL COAST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHENA MEDICAL GROUP OF THE CENTRAL COAST, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326612193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10627
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93912-7627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 ALAMEDA AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93901-4024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-900-5113
Provider Business Practice Location Address Fax Number:
831-900-5113
Provider Enumeration Date:
05/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KHIEU
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
831-665-6084

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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