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General NPI Number Information
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NPI Number | 1285735936
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Entity Type | Organization
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Legal Business Name | BROCKTON SURGICAL CENTER
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 12/11/2007
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Provider Practice Location Address
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Address Line | 5905 BROCKTON AVENUE SUITE B
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City | RIVERSIDE
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State | CA
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Zip | 92506
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Country | US
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Telephone | 951-686-5373
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Fax | 951-781-3661
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Provider Business Mailing Address
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Address Line | 5905 BROCKTON AVENUE SUITE B
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City | RIVERSIDE
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State | CA
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Zip | 92506
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Country | US
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Telephone | 951-686-5373
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Fax | 951-781-3661
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. DONALD GREGORY VOGT
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Credential | DPM
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Telephone | 951-686-5373
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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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