Provider Demographics
NPI:1255722336
Name:NORTHWEST SURGICAL DEVELOPMENT OF FRESNO LLC
Entity type:Organization
Organization Name:NORTHWEST SURGICAL DEVELOPMENT OF FRESNO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-600-9931
Mailing Address - Street 1:65 ENTERPRISE
Mailing Address - Street 2:STE 125
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2706
Mailing Address - Country:US
Mailing Address - Phone:949-600-9931
Mailing Address - Fax:949-600-8029
Practice Address - Street 1:7015 N MAPLE AVE
Practice Address - Street 2:STE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8010
Practice Address - Country:US
Practice Address - Phone:559-325-7855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical