Provider Demographics
NPI:1548311061
Name:SAN LUIS OBISPO EYE ASSOCIATES, A MEDICAL GROUP INC.
Entity type:Organization
Organization Name:SAN LUIS OBISPO EYE ASSOCIATES, A MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-781-3937
Mailing Address - Street 1:234 HEATHER CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-8765
Mailing Address - Country:US
Mailing Address - Phone:805-434-5970
Mailing Address - Fax:805-434-5973
Practice Address - Street 1:689 TANK FARM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-781-3937
Practice Address - Fax:805-781-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X, 332B00000X, 332H00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068240Medicaid
CA=========OtherFEDERAL TAX ID
CA=========OtherFEDERAL TAX ID
CAGR0068240Medicaid
CA1159330001Medicare NSC