=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083922066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE FACE & BODY SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2010
-----------------------------------------------------
Last Update Date | 03/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4906 EL CAMINO REAL SUITE C
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94022-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-967-7834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2449 S KING RD SUITE 10B
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95122-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-238-1978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. BARRY YP FUNG
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 650-967-7834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------