Healthcare Provider Details

I. General information

NPI: 1831177567
Provider Name (Legal Business Name): DE ANZA SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 MAGNOLIA AVE SUITE C
RIVERSIDE CA
92501-4136
US

IV. Provider business mailing address

4444 MAGNOLIA AVE SUITE C
RIVERSIDE CA
92501-4136
US

V. Phone/Fax

Practice location:
  • Phone: 951-320-7799
  • Fax: 951-274-3550
Mailing address:
  • Phone: 951-320-7799
  • Fax: 951-274-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number250000795
License Number StateCA

VIII. Authorized Official

Name: MR. EDWARD J TENNANT
Title or Position: CEO/ADMINISTRATOR
Credential: CASC
Phone: 951-320-7799