Basic Information
| Provider Information | |||||||||
| NPI: | 1538178256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MED-LASER SURGICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2446 W WHITTIER BLVD | ||||||||
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| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906403041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237285500 | ||||||||
| FaxNumber: | 3237284408 | ||||||||
| Practice Location | |||||||||
| Address1: | 2445 W WHITTIER BLVD | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906403069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237272550 | ||||||||
| FaxNumber: | 3237272552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | DE LA PENA | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3237285500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | 930000999 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
No ID Information.