Healthcare Provider Details

I. General information

NPI: 1457643405
Provider Name (Legal Business Name): COFFEE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 19TH ST
BAKERSFIELD CA
93301-3709
US

IV. Provider business mailing address

9709 LAKESIDE BLVD STE 350
SPRING TX
77381-1216
US

V. Phone/Fax

Practice location:
  • Phone: 661-213-4813
  • Fax:
Mailing address:
  • Phone: 713-489-2198
  • Fax: 713-489-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberPENDING
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberPENDING
License Number State

VIII. Authorized Official

Name: DEVIN LARSEN
Title or Position: CEO
Credential:
Phone: 631-445-0593