Provider Demographics
NPI:1376595421
Name:OTAY LAKES SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:OTAY LAKES SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS AND ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KURTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-754-2260
Mailing Address - Street 1:955 LANE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-3501
Mailing Address - Country:US
Mailing Address - Phone:619-754-2260
Mailing Address - Fax:619-754-2261
Practice Address - Street 1:955 LANE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3501
Practice Address - Country:US
Practice Address - Phone:619-754-2260
Practice Address - Fax:619-754-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01779FMedicaid
CA=========OtherW-9 TAX ID
CAS051779Medicare PIN