Healthcare Provider Details

I. General information

NPI: 1578348843
Provider Name (Legal Business Name): GO DEEP ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S MOORPARK RD STE 339
THOUSAND OAKS CA
91361-1008
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-3690
  • Fax: 805-371-4781
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: KENNETH OAKES
Title or Position: PRESIDENT
Credential: CRNA
Phone: 805-512-1456