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General NPI Number Information
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NPI Number | 1447472659
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Entity Type | Organization
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Legal Business Name | BROCKTON ENDOSCOPY SURGERY CENTER LP
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 10/07/2015
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Provider Practice Location Address
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Address Line | 6958 BROCKTON AVE SUITE 100
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City | RIVERSIDE
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State | CA
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Zip | 92506-3829
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Country | US
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Telephone | 951-788-4400
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Fax |
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Provider Business Mailing Address
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Address Line | 6958 BROCKTON AVE SUITE 100
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City | RIVERSIDE
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State | CA
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Zip | 92506-3829
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Country | US
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Telephone | 951-788-4400
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. VINOD MISHRA
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Credential | M.D.
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Telephone | 951-788-4400
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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 | CA
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