MEDICARE: PLAYA ADVANCE SURGICAL INSTITUTE LLC

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

General Provider Information

NPI Number	:	1659624682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLAYA ADVANCE SURGICAL INSTITUTE LLC

Provider Business Mailing Address
First Line	:	4712 ADMIRALTY WAY
Second Line	:	#930
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6905
Country	:	US
Telephone Number	:	310-600-5846
Fax Number	:

Provider Business Practice Location Address
First Line	:	5450 LINCOLN BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90094-2002
Country	:	US
Telephone Number	:	310-600-5846
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MS. GLADYS ANNE HAPPER
Credential	:	NP
Telephone Number	:	310-600-5846

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	10/15/2012

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