Provider Demographics
NPI:1780949594
Name:SOUTH COAST SURGICAL
Entity type:Organization
Organization Name:SOUTH COAST SURGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:STUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-894-4739
Mailing Address - Street 1:40575 CALIF OAKS RD # D2-122
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5797
Mailing Address - Country:US
Mailing Address - Phone:951-894-4739
Mailing Address - Fax:
Practice Address - Street 1:40575 CALIF OAKS RD # D2-122
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5797
Practice Address - Country:US
Practice Address - Phone:951-894-4739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA614072997332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies