Healthcare Provider Details

I. General information

NPI: 1275715922
Provider Name (Legal Business Name): VENICE BEACH SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11961 VENICE BLVD
LOS ANGELES CA
90066-3900
US

IV. Provider business mailing address

11961 VENICE BLVD
LOS ANGELES CA
90066-3900
US

V. Phone/Fax

Practice location:
  • Phone: 310-391-7143
  • Fax: 310-397-9688
Mailing address:
  • Phone: 310-391-7143
  • Fax: 310-397-9688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA41262
License Number StateCA

VIII. Authorized Official

Name: DR. AUGUSTO ROJAS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-391-7143