Provider Demographics
NPI:1952443046
Name:SIERRA VISTA MEDICAL PAVILION AMBULATORY SURGERY SUITE
Entity Type:Organization
Organization Name:SIERRA VISTA MEDICAL PAVILION AMBULATORY SURGERY SUITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-544-6471
Mailing Address - Street 1:77 CASA STREET
Mailing Address - Street 2:STE 203
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405
Mailing Address - Country:US
Mailing Address - Phone:805-544-6471
Mailing Address - Fax:805-544-4913
Practice Address - Street 1:77 CASA STREET
Practice Address - Street 2:STE 203
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-544-6471
Practice Address - Fax:805-544-4913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42294261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750380374OtherNPI NUMBER
CA=========OtherTAX ID NUMBER
E89527Medicare UPIN