Healthcare Provider Details

I. General information

NPI: 1376893784
Provider Name (Legal Business Name): SAN JOAQUIN VALLEY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE STE 240
MODESTO CA
95350-4566
US

IV. Provider business mailing address

269 S BEVERLY DR STE 353
BEVERLY HILLS CA
90212-3851
US

V. Phone/Fax

Practice location:
  • Phone: 888-942-9997
  • 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 State

VIII. Authorized Official

Name: MS. MONICA PORTER
Title or Position: ASSISTANT MANAGER
Credential:
Phone: 888-942-9997