Healthcare Provider Details

I. General information

NPI: 1841858594
Provider Name (Legal Business Name): PACIFIC VISION SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 VAN NESS AVE STE 230
SAN FRANCISCO CA
94102-3271
US

IV. Provider business mailing address

711 VAN NESS AVE STE 230
SAN FRANCISCO CA
94102-3271
US

V. Phone/Fax

Practice location:
  • Phone: 415-997-6410
  • Fax: 415-727-3851
Mailing address:
  • Phone: 415-997-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY BRYAN
Title or Position: PROGRAM MANAGER
Credential:
Phone: 415-420-3934