Provider Demographics
NPI:1932496908
Name:CONCOURSE DIAGNOSTIC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:CONCOURSE DIAGNOSTIC SURGERY CENTER, LLC
Other - Org Name:CONCOURSE DIAGNOSTIC SURGERY CENTER,LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-588-7789
Mailing Address - Street 1:18575 GALE AVE
Mailing Address - Street 2:SUITE#198
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1340
Mailing Address - Country:US
Mailing Address - Phone:626-965-3880
Mailing Address - Fax:626-965-3882
Practice Address - Street 1:707 S GARFIELD AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-5860
Practice Address - Country:US
Practice Address - Phone:626-872-0339
Practice Address - Fax:626-872-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical