Provider Demographics
NPI:1326374844
Name:CREEKSIDE SURGERY SUITE
Entity Type:Organization
Organization Name:CREEKSIDE SURGERY SUITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRIAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MABOURAKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-984-1600
Mailing Address - Street 1:1561 CREEKSIDE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3492
Mailing Address - Country:US
Mailing Address - Phone:916-984-1600
Mailing Address - Fax:916-984-1616
Practice Address - Street 1:1561 CREEKSIDE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3492
Practice Address - Country:US
Practice Address - Phone:916-984-1600
Practice Address - Fax:916-984-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10176261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10176OtherIMQ IDENTIFICATION NUMBER