Healthcare Provider Details

I. General information

NPI: 1407201676
Provider Name (Legal Business Name): CANAAN SURGERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 CRENSHAW BLVD SUITE 200
LOS ANGELES CA
90019-1964
US

IV. Provider business mailing address

903 CRENSHAW BLVD SUITE 200
LOS ANGELES CA
90019-1964
US

V. Phone/Fax

Practice location:
  • Phone: 323-909-6644
  • Fax:
Mailing address:
  • Phone: 323-909-6644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. WALTER JUNG KIM
Title or Position: CEO/MEDICAL DIRECTOR
Credential: M.D.
Phone: 323-909-6644