Basic Information
| Provider Information | |||||||||
| NPI: | 1275532889 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COAST SURGERY CENTER L P | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COAST SURGERY CENTER OF SOUTH BAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3445 PACIFIC COAST HWY | ||||||||
| Address2: | STE 110 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905056658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103254555 | ||||||||
| FaxNumber: | 3103255005 | ||||||||
| Practice Location | |||||||||
| Address1: | 3445 PACIFIC COAST HWY | ||||||||
| Address2: | STE 110 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905056658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103254555 | ||||||||
| FaxNumber: | 3103255005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOON | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER, AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4805670269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | CLN794 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00080885 | 01 | CA | RAILROAD MEDICARE | OTHER |