Healthcare Provider Details

I. General information

NPI: 1679528772
Provider Name (Legal Business Name): ST JOSEPH SURGERY & LASER CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 S GLASSELL ST
ORANGE CA
92866-1906
US

IV. Provider business mailing address

436 S GLASSELL ST
ORANGE CA
92866-1906
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-9566
  • Fax: 714-633-7470
Mailing address:
  • Phone: 714-633-9566
  • Fax: 714-633-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number060000429
License Number StateCA

VIII. Authorized Official

Name: MRS. KATHLEEN RUPER
Title or Position: CEO
Credential:
Phone: 714-633-6060