1053545905 NPI number — SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER

Table of content: (NPI 1053545905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053545905 NPI number — SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER
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:
1053545905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 BAYSIDE DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA DEL MAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92625-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-718-6900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 BAYSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CORONA DEL MAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92625-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-718-6900
Provider Business Practice Location Address Fax Number:
949-718-9367
Provider Enumeration Date:
05/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
NICCOLE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
310-792-3914

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)

  • Identifier: F1929 . This is a "PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com