Provider Demographics
NPI:1235203233
Name:HALLMARK SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:HALLMARK SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-473-1980
Mailing Address - Street 1:4130 HALLMARK PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-1877
Mailing Address - Country:US
Mailing Address - Phone:909-473-1980
Mailing Address - Fax:909-473-1985
Practice Address - Street 1:4130 HALLMARK PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-1877
Practice Address - Country:US
Practice Address - Phone:909-473-1980
Practice Address - Fax:909-473-1985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2007-10-15
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
CA051614OtherBLUE CROSS
CAZZZ25465ZMedicare ID - Type Unspecified