Healthcare Provider Details

I. General information

NPI: 1861180671
Provider Name (Legal Business Name): PROVIDENCE SPECIALTY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 310
ORANGE CA
92868-3838
US

IV. Provider business mailing address

1310 W STEWART DR STE 310
ORANGE CA
92868-3838
US

V. Phone/Fax

Practice location:
  • Phone: 714-204-0444
  • Fax:
Mailing address:
  • Phone: 714-204-0444
  • Fax:

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: MR. JAMSHID SHADJAREH
Title or Position: CHAIRMAN, GOVERNING BODY
Credential:
Phone: 714-204-0444