Provider Demographics
NPI:1669569018
Name:BRENTWOOD SURGERY CENTER INC.
Entity type:Organization
Organization Name:BRENTWOOD SURGERY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:JASSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-444-8808
Mailing Address - Street 1:11819 WILSHIRE BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6631
Mailing Address - Country:US
Mailing Address - Phone:310-444-8808
Mailing Address - Fax:310-444-8809
Practice Address - Street 1:11819 WILSHIRE BLVD STE 215
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6631
Practice Address - Country:US
Practice Address - Phone:310-444-8808
Practice Address - Fax:310-444-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
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
CAS051637Medicare ID - Type Unspecified