Provider Demographics
NPI:1013993252
Name:PASADENA LASER & SURGERY CENTER
Entity Type:Organization
Organization Name:PASADENA LASER & SURGERY CENTER
Other - Org Name:PASEDENA LASER & SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-294-4866
Mailing Address - Street 1:PO BOX 661120
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1120
Mailing Address - Country:US
Mailing Address - Phone:626-294-4866
Mailing Address - Fax:626-294-4872
Practice Address - Street 1:960 E GREEN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2401
Practice Address - Country:US
Practice Address - Phone:626-294-4866
Practice Address - Fax:626-294-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53113208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S051422Medicare ID - Type Unspecified
F89498Medicare UPIN