Basic Information
| Provider Information | |||||||||
| NPI: | 1740553411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIGILANCE PERIOPERATIVE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3098 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905103098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107923914 | ||||||||
| FaxNumber: | 8558984055 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907121419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625312550 | ||||||||
| FaxNumber: | 5626020083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2012 | ||||||||
| LastUpdateDate: | 01/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | VILLARREAL | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3107923914 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1740553411 | 05 | CA | MEDICAID |