Healthcare Provider Details

I. General information

NPI: 1689934457
Provider Name (Legal Business Name): MARINERS SURGICENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 PLACENTIA AVE STE 99 355 PLACENTIA AVE. #104
NEWPORT BEACH CA
92663-3301
US

IV. Provider business mailing address

355 PLACENTIA AVE STE 99 355 PLACENTIA AVE. #104
NEWPORT BEACH CA
92663-3301
US

V. Phone/Fax

Practice location:
  • Phone: 949-650-2345
  • Fax: 949-650-6817
Mailing address:
  • Phone: 949-650-2345
  • Fax: 949-650-6817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberG34385
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID BENVENUTI
Title or Position: OWNER
Credential: M.D.
Phone: 949-650-2345