Healthcare Provider Details

I. General information

NPI: 1619414018
Provider Name (Legal Business Name): DIESEL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD STE 987
LOS ANGELES CA
90025-6814
US

IV. Provider business mailing address

11645 WILSHIRE BLVD STE 987
LOS ANGELES CA
90025-6814
US

V. Phone/Fax

Practice location:
  • Phone: 310-393-9359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA86726
License Number StateCA

VIII. Authorized Official

Name: DAVID GHOZLAND
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-393-9359