Healthcare Provider Details

I. General information

NPI: 1982975959
Provider Name (Legal Business Name): ARCHIBALD SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9674 ARCHIBALD AVE SUITE 125
RANCHO CUCAMONGA CA
91730-7944
US

IV. Provider business mailing address

9674 ARCHIBALD AVE SUITE 125
RANCHO CUCAMONGA CA
91730-7944
US

V. Phone/Fax

Practice location:
  • Phone: 909-989-4100
  • Fax: 909-989-5400
Mailing address:
  • Phone: 909-296-8930
  • Fax: 909-296-8935

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: DR. SUNIL M SHIVARAM
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 909-624-8077