Provider Demographics
NPI:1700985397
Name:SPECIALISTS SURGERY CENTER OF DEL MAR LLC
Entity Type:Organization
Organization Name:SPECIALISTS SURGERY CENTER OF DEL MAR LLC
Other - Org Name:OUTPATIENT SURGERY OF DEL MAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-755-3937
Mailing Address - Street 1:12264 EL CAMINO REAL
Mailing Address - Street 2:SUITE 55
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130
Mailing Address - Country:US
Mailing Address - Phone:858-755-3937
Mailing Address - Fax:858-755-0060
Practice Address - Street 1:12264 EL CAMINO REAL
Practice Address - Street 2:SUITE 55
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130
Practice Address - Country:US
Practice Address - Phone:858-755-3937
Practice Address - Fax:858-755-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63727207W00000X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty