1790799047 NPI number — WATSONVILLE SURGEONS GROUP LLC

Table of content: (NPI 1790799047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790799047 NPI number — WATSONVILLE SURGEONS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATSONVILLE SURGEONS GROUP 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:
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:
1790799047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 GREEN VALLEY RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FREEDOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95019-3160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-763-9700
Provider Business Mailing Address Fax Number:
831-763-9799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 GREEN VALLEY RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FREEDOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95019-3160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-763-9700
Provider Business Practice Location Address Fax Number:
831-763-9799
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALEY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
SEUBERT
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
831-462-5512

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  070000651 , 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: SUR01580F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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