Healthcare Provider Details

I. General information

NPI: 1245374354
Provider Name (Legal Business Name): TRINITY UROLOGICAL & SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S MONTEBELLO BLVD
MONTEBELLO CA
90640-4730
US

IV. Provider business mailing address

126 S MONTEBELLO BLVD
MONTEBELLO CA
90640-4730
US

V. Phone/Fax

Practice location:
  • Phone: 323-720-9204
  • Fax: 323-720-9208
Mailing address:
  • Phone: 323-720-9204
  • Fax: 323-720-9208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA40189
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA40189
License Number StateCA

VIII. Authorized Official

Name: MR. ALEX YACOUB
Title or Position: BILLING OFFICE MANAGER
Credential:
Phone: 323-720-9204