Provider Demographics
NPI:1801045430
Name:SAN DIEGO SPORTS AND MINIMALLY INVASIVE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SAN DIEGO SPORTS AND MINIMALLY INVASIVE SURGERY CENTER LLC
Other - Org Name:SMI SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:D
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-614-3608
Mailing Address - Street 1:3939 RUFFIN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3939 RUFFIN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1815
Practice Address - Country:US
Practice Address - Phone:858-449-4071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical