Healthcare Provider Details

I. General information

NPI: 1801384987
Provider Name (Legal Business Name): EOS WELLNESS SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8641 WILSHIRE BLVD STE 305
BEVERLY HILLS CA
90211-2921
US

IV. Provider business mailing address

8641 WILSHIRE BLVD STE 305
BEVERLY HILLS CA
90211-2921
US

V. Phone/Fax

Practice location:
  • Phone: 310-730-1218
  • Fax: 310-861-1053
Mailing address:
  • Phone: 310-730-1218
  • Fax: 310-861-1053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA112498
License Number StateCA

VIII. Authorized Official

Name: LUANA FARRAR
Title or Position: ACCREDITATION COORDINATOR
Credential:
Phone: 949-337-3267