Healthcare Provider Details

I. General information

NPI: 1720770852
Provider Name (Legal Business Name): SAINT RAPHAEL SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 SEPULVEDA BLVD STE 601
VAN NUYS CA
91411-2699
US

IV. Provider business mailing address

5805 SEPULVEDA BLVD STE 601
VAN NUYS CA
91411-2699
US

V. Phone/Fax

Practice location:
  • Phone: 818-900-6481
  • Fax:
Mailing address:
  • Phone: 818-900-6481
  • Fax:

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: DR. SAMMY EGHBALIEH
Title or Position: PARTNER
Credential: MD
Phone: 818-900-6481