Healthcare Provider Details

I. General information

NPI: 1417315300
Provider Name (Legal Business Name): CALIFORNIA NEUROINTERVENTIONAL SURGEONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

700 E REDLANDS BLVD STE U714
REDLANDS CA
92373-6109
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3000
  • Fax:
Mailing address:
  • Phone: 909-554-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES STOUT
Title or Position: PRESIDENT AND CEO
Credential: MD/PHD
Phone: 909-554-0400