Basic Information
| Provider Information | |||||||||
| NPI: | 1619576824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICARE OF LA VETA, LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEWPORT COAST SURGICAL INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20360 SW BIRCH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926601532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498331432 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20360 SW BIRCH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926601532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498331432 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGINLEY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9496373600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SURGICARE OF LA VETA, LTD. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.