=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336275817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P.S.P. SURGICAL FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 LA VENTA RD STE 202
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-494-3656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 LA VENTA RD STE 202
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-494-3656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OFFICER
-----------------------------------------------------
Name | DR. THEODORE R CORWIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 805-494-3656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------