=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386003390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERWALK SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 03/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4234 RIVERWALK PKWY SUITE 140
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-8510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-509-9204
-----------------------------------------------------
Fax | 951-509-9206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4234 RIVERWALK PKWY SUITE 140
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-8510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-509-9204
-----------------------------------------------------
Fax | 951-509-9206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN, GOVERNING BODY
-----------------------------------------------------
Name | DR. JOSEPH K. KU
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 951-509-9204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------