Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2021-05-10
- Last updated
- 2025-07-16
Specialties
Licenses
- License CA
- 95018635
Location
- Practice location
- 1560 MESA RD STE 100
- City
- NIPOMO CA
- Postal code
- 934446709
- Phone
- 805-614-5640
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.