Basic Information
| Provider Information | |||||||||
| NPI: | 1114317872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN SAMUELI CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 54509 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900540509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144566585 | ||||||||
| FaxNumber: | 7144568101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 BRISTOL ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926268605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144249001 | ||||||||
| FaxNumber: | 7144249005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 02/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | HEYDT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7144562986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.