Healthcare Provider Details

I. General information

NPI: 1669405684
Provider Name (Legal Business Name): PACIFICOAST AMBULATORY SURGICENTER, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 CAMINO DE LOS MARES SUITE 100C
SAN CLEMENTE CA
92673-2859
US

IV. Provider business mailing address

665 CAMINO DE LOS MARES SUITE 100C
SAN CLEMENTE CA
92673-2859
US

V. Phone/Fax

Practice location:
  • Phone: 949-481-7760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number18448
License Number StateCA

VIII. Authorized Official

Name: CHRIS GANGNES
Title or Position: GENERAL MANAGER
Credential:
Phone: 949-276-4141