=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124498357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDOSCOPY CENTER OF INLAND EMPIRE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2015
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40404 CALIFORNIA OAKS RD STE A
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-304-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14201 DALLAS PKWY
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75254-2916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/AO
-----------------------------------------------------
Name | MR. ERIC BOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-567-0269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------