Healthcare Provider Details

I. General information

NPI: 1417051533
Provider Name (Legal Business Name): OAK TREE ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 CORDOVA ST STE 2
PASADENA CA
91101-2617
US

IV. Provider business mailing address

751 CORDOVA ST STE 2
PASADENA CA
91101-2617
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2525
  • Fax: 626-577-2986
Mailing address:
  • Phone: 626-577-2525
  • Fax: 626-577-2986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number930000938
License Number StateCA

VIII. Authorized Official

Name: MR. ROBERT EDMUND WYCOFF
Title or Position: ADMINISTRATOR
Credential: BA
Phone: 626-577-3415