Basic Information
| Provider Information | |||||||||
| NPI: | 1972038818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONCIERGE SURGICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 OAK PARK BLVD | ||||||||
| Address2: | STE 301 | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934201800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054746383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 860 OAK PARK BLVD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934201800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054746383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | LEA | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CRNA | ||||||||
| AuthorizedOfficialTelephone: | 8054746383 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 57590 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.