Basic Information
Provider Information | |||||||||
NPI: | 1730378498 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TORRANCE CA MULTISPECIALTY ASC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SURGERY CENTER OF SOUTH BAY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23500 MADISON ST | ||||||||
Address2: |   | ||||||||
City: | TORRANCE | ||||||||
State: | CA | ||||||||
PostalCode: | 905054702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107842710 | ||||||||
FaxNumber: | 3103269137 | ||||||||
Practice Location | |||||||||
Address1: | 23500 MADISON ST | ||||||||
Address2: |   | ||||||||
City: | TORRANCE | ||||||||
State: | CA | ||||||||
PostalCode: | 905054702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107842710 | ||||||||
FaxNumber: | 3103269137 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2007 | ||||||||
LastUpdateDate: | 04/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLENDENIN | ||||||||
AuthorizedOfficialFirstName: | PHILLIP | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6156651283 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 930000223 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | P00724945 | 01 | CA | RAILROAD | OTHER | SUR01013G | 05 | CA |   | MEDICAID |