Basic Information
| Provider Information | |||||||||
| NPI: | 1073588646 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESCONDIDO CA ENDOSCOPY ASC LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKWAY ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 488 E VALLEY PKWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607356290 | ||||||||
| FaxNumber: | 7607356296 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 E VALLEY PKWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607356290 | ||||||||
| FaxNumber: | 7607356296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 080000655 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 6834236 | 05 | CA | MEDICAID |