Provider Demographics
NPI:1407035215
Name:BUENA VISTA SURGERY CENTER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BUENA VISTA SURGERY CENTER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:W
Authorized Official - Last Name:ODELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-679-7560
Mailing Address - Street 1:121 GRAY AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-1800
Mailing Address - Country:US
Mailing Address - Phone:888-282-7472
Mailing Address - Fax:805-563-5410
Practice Address - Street 1:2701 W. ALAMEDA AVENUE
Practice Address - Street 2:SUITE 401B
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4409
Practice Address - Country:US
Practice Address - Phone:805-823-6688
Practice Address - Fax:805-617-1743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2014-09-22
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
CAS051407Medicare PIN