Basic Information
| Provider Information | |||||||||
| NPI: | 1396700753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALCYON LASER & SURGERY CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 S HALCYON RD | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054898254 | ||||||||
| FaxNumber: | 8054741997 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S HALCYON RD | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054898254 | ||||||||
| FaxNumber: | 8054741997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | SANJA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8055411342 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 051344 | 01 | CA | BLUE CROSS OF CALIFORNIA | OTHER | SUR01344F | 05 | CA | MEDICAID | ZZZH4003Z | 01 | CA | BLUE SHIELD OF CA | OTHER |