Healthcare Provider Details

I. General information

NPI: 1962734186
Provider Name (Legal Business Name): LA MESA SURGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8554 LA MESA BLVD
LA MESA CA
91942-9558
US

IV. Provider business mailing address

8554 LA MESA BLVD
LA MESA CA
91942-9558
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-4469
  • Fax: 619-330-2245
Mailing address:
  • Phone: 619-464-4469
  • Fax: 619-330-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA86720
License Number StateCA

VIII. Authorized Official

Name: DR. PHILLIP DICKINSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-464-4469