Healthcare Provider Details

I. General information

NPI: 1639381783
Provider Name (Legal Business Name): SURGICAL ARTS OF THE INLAND EMPIRE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8680 MONROE CT #100
RANCHO CUCAMONGA CA
91730-4880
US

IV. Provider business mailing address

8680 MONROE CT. #100
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 909-579-3111
  • Fax:
Mailing address:
  • Phone: 909-579-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACOB HAIAVY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-579-3111