Healthcare Provider Details

I. General information

NPI: 1124361282
Provider Name (Legal Business Name): BEVERLY HILLS LASKY CLINIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 S LASKY DR SUITE 106
BEVERLY HILLS CA
90212-1720
US

IV. Provider business mailing address

160 S LASKY DR
BEVERLY HILLS CA
90212-1704
US

V. Phone/Fax

Practice location:
  • Phone: 323-301-2178
  • Fax: 866-844-4712
Mailing address:
  • Phone: 323-301-2178
  • Fax: 866-844-4712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberJACHO 538887
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAAAASF 1371
License Number StateCA

VIII. Authorized Official

Name: MR. THOMAS C CLOUD
Title or Position: MEDICAL BILLING MANAGER
Credential: MPH
Phone: 323-301-2178