Healthcare Provider Details

I. General information

NPI: 1073693123
Provider Name (Legal Business Name): PCSC 15 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 TELEGRAPH RD
VENTURA CA
93003-3422
US

IV. Provider business mailing address

3805 TELEGRAPH RD
VENTURA CA
93003-3422
US

V. Phone/Fax

Practice location:
  • Phone: 805-644-9001
  • Fax: 805-654-1103
Mailing address:
  • Phone: 805-644-9001
  • Fax: 805-654-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number050000581
License Number StateCA

VIII. Authorized Official

Name: MR. KEITH WINTERMUTE
Title or Position: ADMINISTRATOR
Credential:
Phone: 805-644-9001