=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336294859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOS ROBLES SURGICENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2190 LYNN RD SUITE 100
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-497-3737
-----------------------------------------------------
Fax | 805-373-8878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2190 LYNN RD SUITE 100
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-497-3737
-----------------------------------------------------
Fax | 805-373-8878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | WILLIAM GREGORY SWINNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-789-2877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 05000028
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------