Provider Demographics
NPI:1679528772
Name:ST JOSEPH SURGERY & LASER CENTER INC
Entity Type:Organization
Organization Name:ST JOSEPH SURGERY & LASER CENTER INC
Other - Org Name:SAINT MARY AND JOSEPH SURGERY AND LASER CENTER, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-633-6060
Mailing Address - Street 1:436 S GLASSELL ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1906
Mailing Address - Country:US
Mailing Address - Phone:714-633-9566
Mailing Address - Fax:714-633-7470
Practice Address - Street 1:436 S GLASSELL ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1906
Practice Address - Country:US
Practice Address - Phone:714-633-9566
Practice Address - Fax:714-633-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000429261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR70020FMedicaid
CAZZZH4044ZOtherBLUE SHIELD
CAS051332Medicare PIN
CASUR70020FMedicaid
CA000010561Medicare PIN
CA490003001Medicare PIN