Basic Information
| Provider Information | |||||||||
| NPI: | 1972649804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGICAL INSTITUTE OF SOUTHERN CALIFORNIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 BALBOA BLVD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913161502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187848975 | ||||||||
| FaxNumber: | 8187847467 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 BALBOA BLVD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913161502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187848975 | ||||||||
| FaxNumber: | 8187847467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | LYNCH | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8187848975 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 930000931 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.