Healthcare Provider Details

I. General information

NPI: 1487629986
Provider Name (Legal Business Name): SAN LUIS OBISPO CA ENDOSCOPY ASC LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CASA ST SUITE 106
SAN LUIS OBISPO CA
93405-5803
US

IV. Provider business mailing address

77 CASA ST SUITE 106
SAN LUIS OBISPO CA
93405-5803
US

V. Phone/Fax

Practice location:
  • Phone: 805-541-1021
  • Fax: 805-541-3142
Mailing address:
  • Phone: 805-541-1021
  • Fax: 805-541-3142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number050000424
License Number StateCA

VIII. Authorized Official

Name: MR. JEFFREY SNODGRASS
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283