Provider Demographics
NPI:1679010417
Name:PIVAC ASC LLC
Entity Type:Organization
Organization Name:PIVAC ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-348-9604
Mailing Address - Street 1:40 VALLEY STREAM PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6076 BRISTOL PKWY
Practice Address - Street 2:SUITE 108
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6600
Practice Address - Country:US
Practice Address - Phone:310-348-9604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical