Provider Demographics
NPI:1487629986
Name:SAN LUIS OBISPO CA ENDOSCOPY ASC LP
Entity type:Organization
Organization Name:SAN LUIS OBISPO CA ENDOSCOPY ASC LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:77 CASA ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-5803
Mailing Address - Country:US
Mailing Address - Phone:805-541-1021
Mailing Address - Fax:805-541-3142
Practice Address - Street 1:77 CASA ST
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:805-541-1021
Practice Address - Fax:805-541-3142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000424261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01318FMedicaid
CAP00638978OtherRAILROAD
CA490002620Medicare PIN
CAP00638978OtherRAILROAD
CASUR01318FMedicaid