1215310909 NPI number — IB SURGERY INC

Table of content: (NPI 1215310909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215310909 NPI number — IB SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IB SURGERY 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:
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:
1215310909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1792
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91785-1792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-410-6100
Provider Business Mailing Address Fax Number:
761-854-4100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12740 HESPERIA RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-410-6100
Provider Business Practice Location Address Fax Number:
760-854-4100
Provider Enumeration Date:
06/30/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOUARI
Authorized Official First Name:
IRENE
Authorized Official Middle Name:
BIELAWIEC
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
973-738-7336

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A117875 , 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)