Provider Demographics
NPI:1629482609
Name:NORTHWEST SURGICAL DEVELOPMENT OF IRVINE
Entity Type:Organization
Organization Name:NORTHWEST SURGICAL DEVELOPMENT OF IRVINE
Other - Org Name:ATHENIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-600-9931
Mailing Address - Street 1:65 ENTERPRISE STE 125
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2706
Mailing Address - Country:US
Mailing Address - Phone:949-600-9931
Mailing Address - Fax:949-600-8029
Practice Address - Street 1:113 WATERWORKS WAY STE 300
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3174
Practice Address - Country:US
Practice Address - Phone:949-450-0596
Practice Address - Fax:949-450-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10305261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical