1245876937 NPI number — DTLA PAIN SURGERY CENTER INC

Table of content: MELISSA JENNIFER SAKKOS LSW (NPI 1497336358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245876937 NPI number — DTLA PAIN SURGERY CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DTLA PAIN SURGERY CENTER 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:
1245876937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 HOLLAND
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-2568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-588-2190
Provider Business Mailing Address Fax Number:
949-588-2199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1513 S GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE 380
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90015-3070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-872-2633
Provider Business Practice Location Address Fax Number:
888-885-5414
Provider Enumeration Date:
11/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BADDAY
Authorized Official First Name:
HASAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
949-872-2633

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)

  • Identifier: 1669470068 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1437700465 . This is a "ASC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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