1447472659 NPI number — BROCKTON ENDOSCOPY SURGERY CENTER LP

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 1447472659 NPI number — BROCKTON ENDOSCOPY SURGERY CENTER LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROCKTON ENDOSCOPY SURGERY CENTER LP
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:
Provider Other Organization Name Type Code:
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:
1447472659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6958 BROCKTON AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92506-3829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-788-4400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6958 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92506-3829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-788-4400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MISHRA
Authorized Official First Name:
VINOD
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
951-788-4400

Provider Taxonomy Codes

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

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





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