Provider Demographics
NPI:1073665071
Name:MONTEBELLO SURGERY CENTER
Entity Type:Organization
Organization Name:MONTEBELLO SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-728-7998
Mailing Address - Street 1:229 E BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3776
Mailing Address - Country:US
Mailing Address - Phone:323-728-7998
Mailing Address - Fax:323-728-5041
Practice Address - Street 1:229 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3776
Practice Address - Country:US
Practice Address - Phone:323-728-7998
Practice Address - Fax:323-728-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR0122OFMedicaid
CASUR0122OFMedicaid