Provider Demographics
NPI:1932275054
Name:SAN VICENTE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SAN VICENTE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNING BODY
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BROURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-289-8600
Mailing Address - Street 1:11645 WILSHIRE BLVD STE 987
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6814
Mailing Address - Country:US
Mailing Address - Phone:310-289-8600
Mailing Address - Fax:
Practice Address - Street 1:11645 WILSHIRE BLVD STE 987
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6814
Practice Address - Country:US
Practice Address - Phone:310-289-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG48327Medicare PIN
CAA92809Medicare UPIN
CA0779180001Medicare NSC