Healthcare Provider Details

I. General information

NPI: 1447472659
Provider Name (Legal Business Name): BROCKTON ENDOSCOPY SURGERY CENTER LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6958 BROCKTON AVE SUITE 100
RIVERSIDE CA
92506-3829
US

IV. Provider business mailing address

6958 BROCKTON AVE SUITE 100
RIVERSIDE CA
92506-3829
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-4400
  • Fax:
Mailing address:
  • Phone: 951-788-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. VINOD MISHRA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 951-788-4400