Healthcare Provider Details

I. General information

NPI: 1124187208
Provider Name (Legal Business Name): SURGICAL SUITE OF SOUTHERN CALIFORNIA, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 ELM AVE STE 100
LONG BEACH CA
90813-3265
US

IV. Provider business mailing address

PO BOX 2677
LOS ALAMITOS CA
90720-7677
US

V. Phone/Fax

Practice location:
  • Phone: 562-591-4444
  • Fax: 562-436-7350
Mailing address:
  • Phone: 714-935-0073
  • Fax: 714-935-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAAAHC21768
License Number StateCA

VIII. Authorized Official

Name: MS. BARBARA JO CLEM
Title or Position: BILLING AND CONTRACTING
Credential: RN, CPC
Phone: 714-935-0073