Provider Demographics
NPI:1275268120
Name:MDR SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MDR SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-995-5071
Mailing Address - Street 1:13160 MINDANAO WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7915
Mailing Address - Country:US
Mailing Address - Phone:310-574-2103
Mailing Address - Fax:310-640-6069
Practice Address - Street 1:13160 MINDANAO WAY STE 202
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7915
Practice Address - Country:US
Practice Address - Phone:310-574-2103
Practice Address - Fax:310-640-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical