Healthcare Provider Details

I. General information

NPI: 1679010417
Provider Name (Legal Business Name): PIVAC ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6076 BRISTOL PKWY SUITE 108
CULVER CITY CA
90230-6600
US

IV. Provider business mailing address

40 VALLEY STREAM PKWY SUITE 100
MALVERN PA
19355-1407
US

V. Phone/Fax

Practice location:
  • Phone: 310-348-9604
  • Fax:
Mailing address:
  • Phone:
  • 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: SPENCER L. BROWN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-348-9604