Basic Information
Provider Information | |||||||||
NPI: | 1457822298 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVANI OUTPATIENT SURGICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16311 VENTURA BLVD. | ||||||||
Address2: | #710 | ||||||||
City: | ENCINO | ||||||||
State: | CA | ||||||||
PostalCode: | 91436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182059500 | ||||||||
FaxNumber: | 8189904453 | ||||||||
Practice Location | |||||||||
Address1: | 16311 VENTURA BLVD. | ||||||||
Address2: | #710 | ||||||||
City: | ENCINO | ||||||||
State: | CA | ||||||||
PostalCode: | 91436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182059500 | ||||||||
FaxNumber: | 8189904453 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2018 | ||||||||
LastUpdateDate: | 10/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEAL | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8182059500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 10/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.