=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447994116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERMOSA SURGERY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2022
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 PIER AVE STE 1
-----------------------------------------------------
City | HERMOSA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90254-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-488-0500
-----------------------------------------------------
Fax | 424-488-0498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3129
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90510-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-792-3914
-----------------------------------------------------
Fax | 855-898-4055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. BAO NGUYEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-792-3914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------