Provider Demographics
NPI:1265859573
Name:MODESTO SPECIALTY SURGERY CENTER, PC
Entity type:Organization
Organization Name:MODESTO SPECIALTY SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:TAHERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-922-1412
Mailing Address - Street 1:PO BOX 16297
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-2297
Mailing Address - Country:US
Mailing Address - Phone:800-991-6448
Mailing Address - Fax:424-369-9555
Practice Address - Street 1:3105 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1439
Practice Address - Country:US
Practice Address - Phone:800-991-6448
Practice Address - Fax:424-369-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherADDRESS 3105 MCHENRY