Healthcare Provider Details

I. General information

NPI: 1023620572
Provider Name (Legal Business Name): ENDOVASCULAR SURGICAL ASSOCIATES OF LOS ANGELES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 E IMPERIAL HWY STE 502
LYNWOOD CA
90262-2661
US

IV. Provider business mailing address

3680 E IMPERIAL HWY STE 502
LYNWOOD CA
90262-2661
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-0271
  • Fax: 562-698-7467
Mailing address:
  • Phone: 562-698-0271
  • Fax: 562-698-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER J MARROCCO
Title or Position: OWNER
Credential: MD
Phone: 562-698-0271