Basic Information
Provider Information | |||||||||
NPI: | 1215338868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEMORIALCARE SURGICAL CENTER AT SADDLEBACK LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAGUNA NIGUEL SURGERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27882 FORBES RD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | LAGUNA NIGUEL | ||||||||
State: | CA | ||||||||
PostalCode: | 926771267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493472400 | ||||||||
FaxNumber: | 9493472424 | ||||||||
Practice Location | |||||||||
Address1: | 27882 FORBES RD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | LAGUNA NIGUEL | ||||||||
State: | CA | ||||||||
PostalCode: | 926771267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493472400 | ||||||||
FaxNumber: | 9493472424 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2014 | ||||||||
LastUpdateDate: | 09/12/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FIELDS | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2055452572 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.