Provider Demographics
NPI:1346649480
Name:HACIENDA OUTPATIENT SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:HACIENDA OUTPATIENT SURGERY CENTER, LLC
Other - Org Name:HACIENDA SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:4626 WILLOW RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8517
Mailing Address - Country:US
Mailing Address - Phone:925-734-6744
Mailing Address - Fax:925-734-6769
Practice Address - Street 1:4626 WILLOW RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8517
Practice Address - Country:US
Practice Address - Phone:925-734-6744
Practice Address - Fax:925-734-6769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA138693Medicare UPIN