Provider Demographics
NPI:1033114764
Name:PREMIER OUTPATIENT SURGERY CENTER, INC.
Entity Type:Organization
Organization Name:PREMIER OUTPATIENT SURGERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-370-2190
Mailing Address - Street 1:900 E WASHINGTON ST
Mailing Address - Street 2:STE 155
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4196
Mailing Address - Country:US
Mailing Address - Phone:909-370-2190
Mailing Address - Fax:909-370-2266
Practice Address - Street 1:900 E WASHINGTON ST
Practice Address - Street 2:STE 155
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4196
Practice Address - Country:US
Practice Address - Phone:909-370-2190
Practice Address - Fax:909-370-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000827261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01516FMedicaid
CASUR01516FMedicaid