Healthcare Provider Details

I. General information

NPI: 1497788145
Provider Name (Legal Business Name): ENDOSCOPY CENTER OF SOUTHERN CALIFORNIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 SANTA MONICA BLVD STE 204
SANTA MONICA CA
90404-2938
US

IV. Provider business mailing address

2336 SANTA MONICA BLVD SUITE #204
SANTA MONICA CA
90404-2095
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-4477
  • Fax: 310-315-0204
Mailing address:
  • Phone: 310-829-6789
  • Fax: 310-315-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: ERIC BOON
Title or Position: AO
Credential:
Phone: 480-567-0269