Healthcare Provider Details

I. General information

NPI: 1467289884
Provider Name (Legal Business Name): ELITE SPECIALTY SURGERY CENTER OF CHULA VISTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 LANDIS AVE
CHULA VISTA CA
91910-2650
US

IV. Provider business mailing address

1045 E PENNSYLVANIA AVE
ESCONDIDO CA
92025-4616
US

V. Phone/Fax

Practice location:
  • Phone: 619-616-7641
  • Fax:
Mailing address:
  • Phone: 760-884-4500
  • Fax: 619-567-7775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER SALLOUM
Title or Position: CEO
Credential: MD
Phone: 619-616-7641