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General NPI Number Information
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NPI Number | 1043572373
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Entity Type | Organization
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Legal Business Name | FARWELL SURGICENTER
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 06/20/2012
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Provider Practice Location Address
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Address Line | 39180 FARWELL DR
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City | FREMONT
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State | CA
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Zip | 94538-1015
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Country | US
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Telephone | 510-857-1004
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Fax |
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Provider Business Mailing Address
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Address Line | 5178 MOWRY AVE SUITE 2114
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City | FREMONT
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State | CA
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Zip | 94538-1046
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MICHAEL HEIFFERON
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Credential |
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Telephone | 510-857-1004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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