Healthcare Provider Details

I. General information

NPI: 1861014599
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA SURGICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8554 LA MESA BLVD
LA MESA CA
91942-9558
US

IV. Provider business mailing address

6415 REFLECTION DR APT 206
SAN DIEGO CA
92124-3167
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-4469
  • Fax: 619-713-0479
Mailing address:
  • Phone: 508-898-0986
  • Fax: 619-330-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY WANNARES
Title or Position: PRESIDENT
Credential: MD
Phone: 508-898-0986