Provider Demographics
NPI:1710152590
Name:STATE OF THE ART SURGERY CENTER
Entity Type:Organization
Organization Name:STATE OF THE ART SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLENBOGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-276-3183
Mailing Address - Street 1:9201 W SUNSET BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3701
Mailing Address - Country:US
Mailing Address - Phone:310-276-3183
Mailing Address - Fax:310-276-9154
Practice Address - Street 1:9201 W SUNSET BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-3701
Practice Address - Country:US
Practice Address - Phone:310-276-3183
Practice Address - Fax:310-276-9154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1787947261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical