=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083944375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OBSERVATORY SURGERY CENTER LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2010
-----------------------------------------------------
Last Update Date | 01/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 271 OBSERVATORY AVE
-----------------------------------------------------
City | UKIAH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95482-5757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-462-2299
-----------------------------------------------------
Fax | 707-462-1194
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 271 OBSERVATORY AVE
-----------------------------------------------------
City | UKIAH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95482-5757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-462-2299
-----------------------------------------------------
Fax | 707-462-1194
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/ OWNER
-----------------------------------------------------
Name | MR. HARRY B MATOSSIAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 707-462-0681
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------