Provider Demographics
NPI:1124045059
Name:CARDIOVASCULAR CENTER OF LOMPOC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CARDIOVASCULAR CENTER OF LOMPOC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:COUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC
Authorized Official - Phone:805-735-7771
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93438-0567
Mailing Address - Country:US
Mailing Address - Phone:805-736-1875
Mailing Address - Fax:805-735-9911
Practice Address - Street 1:136 N 3RD ST STE 1
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7002
Practice Address - Country:US
Practice Address - Phone:805-735-7771
Practice Address - Fax:805-735-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31374291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ38994ZOtherBLUE SHIELD OF CALIFORNIA
CA00C313740Medicaid
CA00C313740Medicaid
CAHW12139Medicare PIN
CAZZZ38994ZOtherBLUE SHIELD OF CALIFORNIA
CAW12139Medicare PIN