Provider Demographics
NPI:1558832741
Name:GRAND AVENUE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:GRAND AVENUE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-984-4734
Mailing Address - Street 1:1400 S GRAND AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3068
Mailing Address - Country:US
Mailing Address - Phone:213-866-1900
Mailing Address - Fax:213-275-1393
Practice Address - Street 1:1400 S GRAND AVE STE 700
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3068
Practice Address - Country:US
Practice Address - Phone:213-866-1900
Practice Address - Fax:213-275-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical