Provider Demographics
NPI:1689934457
Name:MARINERS SURGICENTER
Entity Type:Organization
Organization Name:MARINERS SURGICENTER
Other - Org Name:DAVID BENVENUTI M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BENVENUTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-650-2345
Mailing Address - Street 1:355 PLACENTIA AVE STE 99
Mailing Address - Street 2:355 PLACENTIA AVE. #104
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3301
Mailing Address - Country:US
Mailing Address - Phone:949-650-2345
Mailing Address - Fax:949-650-6817
Practice Address - Street 1:355 PLACENTIA AVE STE 99
Practice Address - Street 2:355 PLACENTIA AVE. #104
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3301
Practice Address - Country:US
Practice Address - Phone:949-650-2345
Practice Address - Fax:949-650-6817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34385261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical