Provider Demographics
NPI:1871537779
Name:CENTRAL COAST ORTHOPEDIC MEDICAL GROUP
Entity type:Organization
Organization Name:CENTRAL COAST ORTHOPEDIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-349-9545
Mailing Address - Street 1:2342 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1630
Mailing Address - Country:US
Mailing Address - Phone:805-349-9545
Mailing Address - Fax:805-349-9055
Practice Address - Street 1:862 MEINECKE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1721
Practice Address - Country:US
Practice Address - Phone:805-541-4600
Practice Address - Fax:805-541-3566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14365AMedicare ID - Type Unspecified