Healthcare Provider Details

I. General information

NPI: 1972038818
Provider Name (Legal Business Name): CONCIERGE SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 OAK PARK BLVD STE 102
ARROYO GRANDE CA
93420-1800
US

IV. Provider business mailing address

860 OAK PARK BLVD STE 301
ARROYO GRANDE CA
93420-1800
US

V. Phone/Fax

Practice location:
  • Phone: 805-474-6383
  • Fax:
Mailing address:
  • Phone: 805-474-6383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number57590
License Number StateCA

VIII. Authorized Official

Name: MR. SHAUN LEA
Title or Position: CRNA
Credential: CRNA
Phone: 805-474-6383