Basic Information
| Provider Information | |||||||||
| NPI: | 1811994080 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC ENDO-SURGICAL CENTER, LP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PACIFIC ENDO-SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3445 PACIFIC COAST HWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905056658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103261666 | ||||||||
| FaxNumber: | 3103269666 | ||||||||
| Practice Location | |||||||||
| Address1: | 3445 PACIFIC COAST HWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905056658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103261666 | ||||||||
| FaxNumber: | 3103269666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2005 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DRISKILL | ||||||||
| AuthorizedOfficialFirstName: | JEANETTE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3103261666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 930000979 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.