1922625995 NPI number — NATIONAL SURGICAL CENTERS STOCKTON, 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 1922625995 NPI number — NATIONAL SURGICAL CENTERS STOCKTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONAL SURGICAL CENTERS STOCKTON, 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:
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:
1922625995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
561 WINDING BROOK FARM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06795-1747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-919-9560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 E HARDING WAY STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95204-6118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-919-9560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BOONE
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF NURSING OFFICER
Authorized Official Telephone Number:
312-919-9560

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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