Basic Information
| Provider Information | |||||||||
| NPI: | 1952355422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENEFIT SURGERY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENEFIT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9674 ARCHIBALD AVE | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099894100 | ||||||||
| FaxNumber: | 9099895400 | ||||||||
| Practice Location | |||||||||
| Address1: | 9674 ARCHIBALD AVE | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099894100 | ||||||||
| FaxNumber: | 9099895400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | YONG | ||||||||
| AuthorizedOfficialMiddleName: | TAI | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9099894100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 240000845 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 240000845 | 01 | CA | SURG. CLINIC LICENSE DHS | OTHER |