Provider Demographics
NPI:1679694392
Name:DIRECTED INTERVENTIONAL SURGERY CTR INC A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:DIRECTED INTERVENTIONAL SURGERY CTR INC A PROFESSIONAL MEDICAL CORP
Other - Org Name:DIRECTED INTERVENTIONAL SURGERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-829-9788
Mailing Address - Street 1:2827 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-829-9788
Mailing Address - Fax:310-453-1576
Practice Address - Street 1:2827 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4801
Practice Address - Country:US
Practice Address - Phone:310-829-9788
Practice Address - Fax:310-453-1576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS051520261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0070730Medicaid
CAGR0070730Medicaid