Basic Information
| Provider Information | |||||||||
| NPI: | 1619414018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIESEL SURGERY CENTER | ||||||||
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| OtherOrganizationName: | DIESEL SURGERY CENTER, LP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11645 WILSHIRE BLVD STE 987 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900256814 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11645 WILSHIRE BLVD STE 987 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900256814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103939359 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | GHOZLAND | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3103939359 | ||||||||
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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 | 207V00000X | A86726 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.