Healthcare Provider Details

I. General information

NPI: 1780277012
Provider Name (Legal Business Name): INTEGRATIVE OPERATING THEATRES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9675 BRIGHTON WAY STE B1
BEVERLY HILLS CA
90210-5144
US

IV. Provider business mailing address

9675 BRIGHTON WAY STE 380
BEVERLY HILLS CA
90210-5187
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-3007
  • Fax: 310-733-1818
Mailing address:
  • Phone: 310-273-3007
  • Fax: 310-733-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GLENN VALLECILLOS
Title or Position: CEO/MEDICAL DIRECTOR
Credential: MD
Phone: 310-273-3007