Basic Information
| Provider Information | |||||||||
| NPI: | 1073753406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERMOSA STREET SURGERY, A MEDICAL CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERMOSA SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD | ||||||||
| Address2: | STE. 440 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
| FaxNumber: | 3104729582 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 SOLAR DRIVE | ||||||||
| Address2: | #160 | ||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059831999 | ||||||||
| FaxNumber: | 8054859490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2009 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | STARR | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8059831999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.