Provider Demographics
NPI:1548583651
Name:PENINSULA ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:PENINSULA ENDOSCOPY CENTER LLC
Other - Org Name:MID PENINSULA ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO ADN AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-566-4770
Mailing Address - Street 1:1720 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3224
Mailing Address - Country:US
Mailing Address - Phone:650-373-1970
Mailing Address - Fax:
Practice Address - Street 1:1720 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3224
Practice Address - Country:US
Practice Address - Phone:650-373-1970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy