Healthcare Provider Details

I. General information

NPI: 1376595421
Provider Name (Legal Business Name): OTAY LAKES SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 LANE AVE SUITE 100
CHULA VISTA CA
91914-3501
US

IV. Provider business mailing address

955 LANE AVE SUITE 100
CHULA VISTA CA
91914-3501
US

V. Phone/Fax

Practice location:
  • Phone: 619-754-2260
  • Fax: 619-754-2261
Mailing address:
  • Phone: 619-754-2260
  • Fax: 619-754-2261

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: MR. GARY KURTH
Title or Position: VP OPERATIONS AND ADMINISTRATION
Credential:
Phone: 619-754-2260