Healthcare Provider Details

I. General information

NPI: 1972649804
Provider Name (Legal Business Name): UROLOGICAL INSTITUTE OF SOUTHERN CALIFORNIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BALBOA BLVD SUITE 111
ENCINO CA
91316-1502
US

IV. Provider business mailing address

5400 BALBOA BLVD SUITE 111
ENCINO CA
91316-1502
US

V. Phone/Fax

Practice location:
  • Phone: 818-784-8975
  • Fax: 818-784-7467
Mailing address:
  • Phone: 818-784-8975
  • Fax: 818-784-7467

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: MRS. KIM LYNCH
Title or Position: ADMINISTRATOR
Credential:
Phone: 818-784-8975