Healthcare Provider Details

I. General information

NPI: 1093843120
Provider Name (Legal Business Name): MANCHESTER SURGICAL PAVILLION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MANCHESTER AVE SUITE 650
ORANGE CA
92868-3217
US

IV. Provider business mailing address

PO BOX 515072
LOS ANGELES CA
90051-5072
US

V. Phone/Fax

Practice location:
  • Phone: 310-202-6204
  • Fax: 310-202-0831
Mailing address:
  • Phone: 310-202-6204
  • Fax: 310-202-0831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGORY EVANS
Title or Position: CHAIR
Credential: M.D.
Phone: 714-456-3228