Healthcare Provider Details

I. General information

NPI: 1982288049
Provider Name (Legal Business Name): CARDIOVASCULAR INTERVENTIONAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 S BRISTOL ST STE 108B
SANTA ANA CA
92704-5718
US

IV. Provider business mailing address

2621 S BRISTOL ST STE 108B
SANTA ANA CA
92704-5718
US

V. Phone/Fax

Practice location:
  • Phone: 714-754-1684
  • Fax: 714-966-0417
Mailing address:
  • Phone: 714-754-1684
  • Fax: 714-966-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANIL V SHAH
Title or Position: PRESIDENT
Credential: MD
Phone: 714-290-5322