Healthcare Provider Details

I. General information

NPI: 1154703262
Provider Name (Legal Business Name): INNOVA SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N BEDFORD DR STE 105
BEVERLY HILLS CA
90210-4323
US

IV. Provider business mailing address

436 N BEDFORD DR STE 105
BEVERLY HILLS CA
90210-4323
US

V. Phone/Fax

Practice location:
  • Phone: 310-385-8819
  • Fax:
Mailing address:
  • Phone: 310-385-8819
  • Fax:

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: LISA CASSILETH
Title or Position: PRESIDENT
Credential: MD
Phone: 310-278-8200