Basic Information
| Provider Information | |||||||||
| NPI: | 1750308763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL SPECIALTIES OF ARROYO GRANDE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 OAK PARK BLVD | ||||||||
| Address2: | 102 | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934201800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054746383 | ||||||||
| FaxNumber: | 8054746387 | ||||||||
| Practice Location | |||||||||
| Address1: | 860 OAK PARK BLVD | ||||||||
| Address2: | 102 | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934201800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054746383 | ||||||||
| FaxNumber: | 8054746387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | FERRO | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8054746383 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 050000571 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 050000571 | 01 | CA | LICENSE | OTHER |