Provider Demographics
NPI:1588679179
Name:SPECIALTY SURGICAL CENTER OF ENCINO LP
Entity Type:Organization
Organization Name:SPECIALTY SURGICAL CENTER OF ENCINO LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:8670 WILSHIRE BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2924
Mailing Address - Country:US
Mailing Address - Phone:310-659-6333
Mailing Address - Fax:310-659-2333
Practice Address - Street 1:16501 VENTURA BLVD
Practice Address - Street 2:STE 103
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2007
Practice Address - Country:US
Practice Address - Phone:310-659-6333
Practice Address - Fax:310-659-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-02-08
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
CAS051531Medicare ID - Type UnspecifiedSO. CAL. PART B