1407035215 NPI number — BUENA VISTA SURGERY CENTER MEDICAL GROUP INC

Table of content: (NPI 1407035215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407035215 NPI number — BUENA VISTA SURGERY CENTER MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUENA VISTA SURGERY CENTER MEDICAL GROUP 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:
1407035215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 GRAY AVENUE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93101-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-282-7472
Provider Business Mailing Address Fax Number:
805-563-5410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2701 W. ALAMEDA AVENUE
Provider Second Line Business Practice Location Address:
SUITE 401B
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91505-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-823-6688
Provider Business Practice Location Address Fax Number:
805-617-1743
Provider Enumeration Date:
10/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ODELL
Authorized Official First Name:
DAVE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
805-679-7560

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)





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