MEDICARE: SAN DIEGO SPORTS AND MINIMALLY INVASIVE SURGERY CENTER 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	:	1801045430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIEGO SPORTS AND MINIMALLY INVASIVE SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	3939 RUFFIN RD
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1815
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 RUFFIN RD
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1815
Country	:	US
Telephone Number	:	858-449-4071
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MR. MARC D JANG
Credential	:
Telephone Number	:	916-614-3608

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	09/18/2008

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