Healthcare Provider Details

I. General information

NPI: 1720129893
Provider Name (Legal Business Name): PACIFIC GASTROENTEROLOGY ENDOSCOPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26421 CROWN VALLEY PKWY SUITE 140B
MISSION VIEJO CA
92691-8564
US

IV. Provider business mailing address

26421 CROWN VALLEY PKWY SUITE 140B
MISSION VIEJO CA
92691-8564
US

V. Phone/Fax

Practice location:
  • Phone: 949-365-8836
  • Fax:
Mailing address:
  • Phone: 949-365-8836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number060000855
License Number StateCA

VIII. Authorized Official

Name: DR. OM P CHAURASIA
Title or Position: PRESIDENT
Credential: MD
Phone: 949-365-8836