Provider Demographics
NPI:1659685881
Name:RENAISSANCE SURGICAL ARTS AT NEWPORT HARBOR, LLC
Entity Type:Organization
Organization Name:RENAISSANCE SURGICAL ARTS AT NEWPORT HARBOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-629-1400
Mailing Address - Street 1:1640 NEWPORT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3786
Mailing Address - Country:US
Mailing Address - Phone:949-629-1400
Mailing Address - Fax:949-629-1500
Practice Address - Street 1:1640 NEWPORT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-629-1400
Practice Address - Fax:949-629-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical