Healthcare Provider Details

I. General information

NPI: 1487042859
Provider Name (Legal Business Name): ELITE SURGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 MOWRY AVE STE.#401
FREMONT CA
94538-1730
US

IV. Provider business mailing address

19197 GOLDEN VALLEY RD ST.#444
CANYON COUNTRY CA
91387-1428
US

V. Phone/Fax

Practice location:
  • Phone: 510-556-1000
  • Fax: 510-878-4444
Mailing address:
  • Phone: 510-556-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NOSRAT KHAJAVI
Title or Position: PRESIDENT/ SOLE OWNER
Credential: M.D.
Phone: 510-556-1000