Provider Demographics
NPI:1881703080
Name:PACIFIC SURGICENTER
Entity type:Organization
Organization Name:PACIFIC SURGICENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVERE
Authorized Official - Middle Name:GARETH
Authorized Official - Last Name:WOOTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-315-0222
Mailing Address - Street 1:1301 20TH ST
Mailing Address - Street 2:#470
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2050
Mailing Address - Country:US
Mailing Address - Phone:310-315-0222
Mailing Address - Fax:310-828-8852
Practice Address - Street 1:1301 20TH ST
Practice Address - Street 2:#470
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-315-0222
Practice Address - Fax:310-828-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051132Medicare ID - Type Unspecified