Healthcare Provider Details

I. General information

NPI: 1407035215
Provider Name (Legal Business Name): BUENA VISTA SURGERY CENTER MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W. ALAMEDA AVENUE SUITE 401B
BURBANK CA
91505-4409
US

IV. Provider business mailing address

121 GRAY AVENUE SUITE 200
SANTA BARBARA CA
93101-1800
US

V. Phone/Fax

Practice location:
  • Phone: 805-823-6688
  • Fax: 805-617-1743
Mailing address:
  • Phone: 888-282-7472
  • Fax: 805-563-5410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAVE W ODELL
Title or Position: MANAGING MEMBER
Credential:
Phone: 805-679-7560