Provider Demographics
NPI:1740891571
Name:PENINSULA SURGERY CENTER, LLC
Entity type:Organization
Organization Name:PENINSULA SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-406-9731
Mailing Address - Street 1:2299 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1621
Mailing Address - Country:US
Mailing Address - Phone:510-406-9731
Mailing Address - Fax:
Practice Address - Street 1:350 MARINE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-5224
Practice Address - Country:US
Practice Address - Phone:510-406-9731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical