=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548403744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STOCKDALE SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2009
-----------------------------------------------------
Last Update Date | 02/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9802 STOCKDALE HWY 104
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-665-7885
-----------------------------------------------------
Fax | 661-735-3941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9802 STOCKDALE HWY 104
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-665-7885
-----------------------------------------------------
Fax | 661-735-3941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | MRS. MARIA RIVAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-665-7885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------