1851695860 NPI number — THE SURGERY CENTER ON SAND CANYON SHADY CANYON EXIT

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 1851695860 NPI number — THE SURGERY CENTER ON SAND CANYON SHADY CANYON EXIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE SURGERY CENTER ON SAND CANYON SHADY CANYON EXIT
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:
1851695860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16300 SAND CANYON AVE
Provider Second Line Business Mailing Address:
SUITE 901
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-677-9695
Provider Business Mailing Address Fax Number:
949-453-8601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16300 SAND CANYON AVE
Provider Second Line Business Practice Location Address:
SUITE 901
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92618-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-677-9695
Provider Business Practice Location Address Fax Number:
949-453-8601
Provider Enumeration Date:
01/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
BEOMJIN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
949-585-9870

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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