Healthcare Provider Details

I. General information

NPI: 1730558156
Provider Name (Legal Business Name): OAKS SURGICAL SUITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 SAINT CHARLES DR SUITE 200
THOUSAND OAKS CA
91360-3903
US

IV. Provider business mailing address

558 SAINT CHARLES DR SUITE 200
THOUSAND OAKS CA
91360-3903
US

V. Phone/Fax

Practice location:
  • Phone: 805-379-2322
  • Fax: 805-379-2373
Mailing address:
  • Phone: 805-379-2322
  • Fax: 805-379-2373

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: RUSSELL W NELSON
Title or Position: MEMBER
Credential: MD
Phone: 805-379-2322