Facts
- Status
- A
- Credential
- D.O.
- Type
- Individual
- Enumeration date
- 2007-02-13
- Last updated
- 2025-02-24
Specialties
Licenses
- License CA
- 20A7253
Location
- Practice location
- 671 W TEFFT ST STE 13
- City
- NIPOMO CA
- Postal code
- 934448988
- Phone
- 805-473-4001
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.