Healthcare Provider Details

I. General information

NPI: 1417405234
Provider Name (Legal Business Name): PSC STOCKTON OUTPATIENT SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 N CALIFORNIA ST SUITE 405
STOCKTON CA
95204-6037
US

IV. Provider business mailing address

1805 N CALIFORNIA ST SUITE 405
STOCKTON CA
95204-6037
US

V. Phone/Fax

Practice location:
  • Phone: 209-870-7100
  • Fax: 209-870-7116
Mailing address:
  • Phone: 209-870-7100
  • Fax: 209-870-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA110013
License Number StateCA

VIII. Authorized Official

Name: DR. NATHAN ANDREW KLUDT
Title or Position: PRESIDENT
Credential: MD
Phone: 209-870-7100