1174987135 NPI number — SURGICAL TREATMENT AND REGENERATION II, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174987135 NPI number — SURGICAL TREATMENT AND REGENERATION II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL TREATMENT AND REGENERATION II, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STAR SURGICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174987135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 S SPALDING DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90212-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-375-3974
Provider Business Mailing Address Fax Number:
760-375-3953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 N SEPULVEDA BLVD
Provider Second Line Business Practice Location Address:
#223
Provider Business Practice Location Address City Name:
MANHATTAN BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90266-2725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-375-3974
Provider Business Practice Location Address Fax Number:
760-375-3953
Provider Enumeration Date:
04/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GHODADRA
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
678-596-1344

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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