Healthcare Provider Details

I. General information

NPI: 1285735936
Provider Name (Legal Business Name): BROCKTON SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 BROCKTON AVENUE SUITE B
RIVERSIDE CA
92506
US

IV. Provider business mailing address

5905 BROCKTON AVENUE SUITE B
RIVERSIDE CA
92506
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-5373
  • Fax: 951-781-3661
Mailing address:
  • Phone: 951-686-5373
  • Fax: 951-781-3661

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: MR. DONALD GREGORY VOGT
Title or Position: ADMINISTRATOR
Credential: DPM
Phone: 951-686-5373