1740267574 NPI number — CENTRAL COAST CHEST CONSULTANTS A MEDICAL CORPORATION

Table of content: (NPI 1740267574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740267574 NPI number — CENTRAL COAST CHEST CONSULTANTS A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL COAST CHEST CONSULTANTS A MEDICAL CORPORATION
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:
CENTRAL COAST CHEST CONSULTANTS MEDICAL CORPORATION
Provider Other Organization Name Type Code:
3
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:
1740267574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93406-2460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-548-1142
Provider Business Mailing Address Fax Number:
805-234-9985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1428 PHILLIPS LN
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-2537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-543-4407
Provider Business Practice Location Address Fax Number:
805-543-4587
Provider Enumeration Date:
12/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SOLL
Authorized Official First Name:
MARK
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-543-4407

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A62340 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 2070377 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 2070377 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZZ138136Z . This is a "BLUE SHIELD PIN - FRENCH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ138137Z . This is a "BLUE SHIELD PIN - SVRMC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ25763Z . This is a "BLUE SHIELD PIN - PHILLIP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0046460 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 184149800 . This is a "US DOL PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ13198Z . This is a "BLUE SHIELD TEMPLETON" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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