=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306882956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN RAMON SURGERY CENTER, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 11/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 PORTER DR STE. 100
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94583-1587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-838-6880
-----------------------------------------------------
Fax | 925-838-6886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11999 SAN VICENTE BL. STE. 440
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-5042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-440-3131
-----------------------------------------------------
Fax | 310-472-9582
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GLEN K. LAU
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 925-838-6880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------