Healthcare Provider Details

I. General information

NPI: 1538775267
Provider Name (Legal Business Name): EV SURGERY INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 03/11/2023
Certification Date: 03/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N BASCOM AVE STE 103
SAN JOSE CA
95128-1811
US

IV. Provider business mailing address

4215 HAMILTON AVE
SAN JOSE CA
95130-1462
US

V. Phone/Fax

Practice location:
  • Phone: 408-761-5847
  • Fax:
Mailing address:
  • Phone: 408-761-5847
  • Fax:

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: MS. BARBARA LEE ROTH
Title or Position: VP OF CLINICAL OPERATIONS
Credential: REGISTERED NURSE
Phone: 408-761-5847