Provider Demographics
NPI:1073693123
Name:PCSC 15 INC
Entity Type:Organization
Organization Name:PCSC 15 INC
Other - Org Name:PACIFIC SURGERY CENTER OF VTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTERMUTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-644-9001
Mailing Address - Street 1:3805 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3422
Mailing Address - Country:US
Mailing Address - Phone:805-644-9001
Mailing Address - Fax:805-654-1103
Practice Address - Street 1:3805 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3422
Practice Address - Country:US
Practice Address - Phone:805-644-9001
Practice Address - Fax:805-654-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000581261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA005279OtherBLUE CROSS PROV. #
CA99204OtherHEALTH PARTNERS PROV. #
CAZZZH5616ZOtherBLUE SHIELD PROV. #
CA005279OtherBLUE CROSS PROV. #