Provider Demographics
NPI:1205599149
Name:BALBOA SURGICAL ASSOCIATES INC.
Entity type:Organization
Organization Name:BALBOA SURGICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-872-5192
Mailing Address - Street 1:129 LESSAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1043
Mailing Address - Country:US
Mailing Address - Phone:949-872-5192
Mailing Address - Fax:
Practice Address - Street 1:2501 E CHAPMAN AVE STE 220
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3108
Practice Address - Country:US
Practice Address - Phone:949-872-5192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty