Provider Demographics
NPI:1841858594
Name:PACIFIC VISION SURGERY CENTER LLC
Entity type:Organization
Organization Name:PACIFIC VISION SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-420-3934
Mailing Address - Street 1:711 VAN NESS AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-3271
Mailing Address - Country:US
Mailing Address - Phone:415-997-6410
Mailing Address - Fax:
Practice Address - Street 1:711 VAN NESS AVE STE 230
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3271
Practice Address - Country:US
Practice Address - Phone:415-997-6410
Practice Address - Fax:415-727-3851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1503942Medicaid