Healthcare Provider Details

I. General information

NPI: 1770652216
Provider Name (Legal Business Name): PENINSULA EYE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 W EL CAMINO REAL
MOUNTAIN VIEW CA
94040-2518
US

IV. Provider business mailing address

1128 W EL CAMINO REAL
MOUNTAIN VIEW CA
94040-2518
US

V. Phone/Fax

Practice location:
  • Phone: 650-964-3200
  • Fax: 650-964-3206
Mailing address:
  • Phone: 650-964-3200
  • Fax: 650-964-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number550000072
License Number StateCA

VIII. Authorized Official

Name: JEFFREY M FIELDS
Title or Position: VP
Credential:
Phone: 205-545-2572