Provider Demographics
NPI:1124187208
Name:SURGICAL SUITE OF SOUTHERN CALIFORNIA, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SURGICAL SUITE OF SOUTHERN CALIFORNIA, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CONTRACTING
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CLEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CPC
Authorized Official - Phone:714-935-0073
Mailing Address - Street 1:PO BOX 2677
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-7677
Mailing Address - Country:US
Mailing Address - Phone:714-935-0073
Mailing Address - Fax:714-935-0075
Practice Address - Street 1:1040 ELM AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3265
Practice Address - Country:US
Practice Address - Phone:562-591-4444
Practice Address - Fax:562-436-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAAAHC21768261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical