Healthcare Provider Details

I. General information

NPI: 1720044605
Provider Name (Legal Business Name): TRACY OUTPATIENT SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W EATON AVE STE P
TRACY CA
95376
US

IV. Provider business mailing address

530 W EATON AVE STE P
TRACY CA
95376
US

V. Phone/Fax

Practice location:
  • Phone: 209-833-8797
  • Fax: 209-835-3246
Mailing address:
  • Phone: 209-833-8797
  • Fax: 209-835-3246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberCA030001797
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberCA030001797
License Number StateCA

VIII. Authorized Official

Name: HARPREET S GREWAL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 209-833-8797