Provider Demographics
NPI:1295769131
Name:90210 SURGERY MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:90210 SURGERY MEDICAL CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ESPARZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-699-0303
Mailing Address - Street 1:450 N ROXBURY DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4232
Mailing Address - Country:US
Mailing Address - Phone:310-651-2280
Mailing Address - Fax:310-651-2260
Practice Address - Street 1:450 N ROXBURY DR
Practice Address - Street 2:SUITE 600
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4232
Practice Address - Country:US
Practice Address - Phone:310-651-2280
Practice Address - Fax:310-651-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01031GMedicaid
CAS051031CMedicare PIN
CASUR01031GMedicaid