Provider Demographics
NPI:1972649804
Name:UROLOGICAL INSTITUTE OF SOUTHERN CALIFORNIA LLC
Entity Type:Organization
Organization Name:UROLOGICAL INSTITUTE OF SOUTHERN CALIFORNIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-784-8975
Mailing Address - Street 1:5400 BALBOA BLVD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1502
Mailing Address - Country:US
Mailing Address - Phone:818-784-8975
Mailing Address - Fax:818-784-7467
Practice Address - Street 1:5400 BALBOA BLVD
Practice Address - Street 2:SUITE 111
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1502
Practice Address - Country:US
Practice Address - Phone:818-784-8975
Practice Address - Fax:818-784-7467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000931261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051441Medicare ID - Type Unspecified