Basic Information
| Provider Information | |||||||||
| NPI: | 1417315300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA NEUROINTERVENTIONAL SURGEONS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E REDLANDS BLVD | ||||||||
| Address2: | STE U714 | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923736109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095540400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
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| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517883000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2016 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | STOUT | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9095540400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD/PHD | ||||||||
| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.