Provider Demographics
NPI:1083732721
Name:ENCINO PLACE SURGERY CENTER
Entity Type:Organization
Organization Name:ENCINO PLACE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-784-9304
Mailing Address - Street 1:5091 WESTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-0231
Mailing Address - Country:US
Mailing Address - Phone:818-784-9304
Mailing Address - Fax:818-784-9307
Practice Address - Street 1:16101 VENTURA BLVD STE 240
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2513
Practice Address - Country:US
Practice Address - Phone:818-784-9304
Practice Address - Fax:818-784-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53604261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical