Healthcare Provider Details

I. General information

NPI: 1568844934
Provider Name (Legal Business Name): FASHION ISLAND SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W LA VETA AVE STE 100
ORANGE CA
92866-2607
US

IV. Provider business mailing address

302 W LA VETA AVE STE 100
ORANGE CA
92866-2607
US

V. Phone/Fax

Practice location:
  • Phone: 661-472-4177
  • Fax: 760-262-3917
Mailing address:
  • Phone: 661-472-4177
  • Fax: 760-262-3917

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. ELENA C SERDA
Title or Position: DIRECTOR
Credential:
Phone: 661-472-4177