Provider Demographics
NPI:1396741807
Name:EAST BAY ENDOSCOPY CENTER L P
Entity type:Organization
Organization Name:EAST BAY ENDOSCOPY CENTER L P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-566-4907
Mailing Address - Street 1:5858 HORTON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2006
Mailing Address - Country:US
Mailing Address - Phone:510-654-4554
Mailing Address - Fax:
Practice Address - Street 1:5858 HORTON ST
Practice Address - Street 2:STE 100
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2007
Practice Address - Country:US
Practice Address - Phone:510-654-4554
Practice Address - Fax:510-654-4594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
20889OtherAAAHC ORGANIZATION ID
CAZZZH0112ZOtherBLUE SHIELD OF CA
CAAURO1463FMedicaid
CA140000597OtherSTATE LICENSE
CAZZZH0112ZOtherBLUE SHIELD OF CA