Healthcare Provider Details

I. General information

NPI: 1023305984
Provider Name (Legal Business Name): LASER & AMBULATORY SURG CTR OF PASA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E. COLORADO BLVD. SUITE 260
PASADENA CA
91101
US

IV. Provider business mailing address

800 E. COLORADO BLVD. SUITE 260
PASADENA CA
91101
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-6494
  • Fax: 626-449-0813
Mailing address:
  • Phone: 626-449-6494
  • Fax: 626-449-0813

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: WARREN STOUT
Title or Position: MD PRESIDENT
Credential: MD
Phone: 626-449-6494