Provider Demographics
NPI:1770652216
Name:PENINSULA EYE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PENINSULA EYE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-545-2572
Mailing Address - Street 1:1128 W EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2518
Mailing Address - Country:US
Mailing Address - Phone:650-964-3200
Mailing Address - Fax:650-964-3206
Practice Address - Street 1:1128 W EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2518
Practice Address - Country:US
Practice Address - Phone:650-964-3200
Practice Address - Fax:650-964-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
CA550000072261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS1737OtherBLUE CROSS
CASUR01737FMedicaid
AS1737OtherBLUE CROSS
ZZZ318562ZMedicare ID - Type Unspecified