MEDICARE: BUENA VISTA SURGERY CENTER MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center		CA

General Provider Information

NPI Number	:	1407035215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUENA VISTA SURGERY CENTER MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	121 GRAY AVENUE
Second Line	:	SUITE 200
City	:	SANTA BARBARA
State	:	CA
Zip	:	93101-1800
Country	:	US
Telephone Number	:	888-282-7472
Fax Number	:	805-563-5410

Provider Business Practice Location Address
First Line	:	2701 W. ALAMEDA AVENUE
Second Line	:	SUITE 401B
City	:	BURBANK
State	:	CA
Zip	:	91505-4409
Country	:	US
Telephone Number	:	805-823-6688
Fax Number	:	805-617-1743

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DAVE W ODELL
Credential	:
Telephone Number	:	805-679-7560

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	09/22/2014

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