Healthcare Provider Details

I. General information

NPI: 1831235878
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA STONE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BALBOA BLVD STE 111
ENCINO CA
91316-5206
US

IV. Provider business mailing address

5400 BALBOA BLVD STE 111
ENCINO CA
91316-5206
US

V. Phone/Fax

Practice location:
  • Phone: 818-784-8975
  • Fax: 818-784-7467
Mailing address:
  • Phone: 814-453-6963
  • Fax: 310-695-2986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number930000931
License Number StateCA

VIII. Authorized Official

Name: CATHERINE LLAVANES
Title or Position: CEO/ OWNER
Credential:
Phone: 818-453-6963