1750308763 NPI number — SURGICAL SPECIALTIES OF ARROYO GRANDE INC.

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 1750308763 NPI number — SURGICAL SPECIALTIES OF ARROYO GRANDE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL SPECIALTIES OF ARROYO GRANDE INC.
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:
6
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:
1750308763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 OAK PARK BLVD
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
ARROYO GRANDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93420-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-474-6383
Provider Business Mailing Address Fax Number:
805-474-6387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 OAK PARK BLVD
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
ARROYO GRANDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93420-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-474-6383
Provider Business Practice Location Address Fax Number:
805-474-6387
Provider Enumeration Date:
07/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FERRO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
805-474-6383

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  050000571 , 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)

  • Identifier: 050000571 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".