=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598049272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA CENTER FOR NEUROINTERVENTIONAL SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2011
-----------------------------------------------------
Last Update Date | 11/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9834 GENESEE AVE 411
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-677-1755
-----------------------------------------------------
Fax | 858-677-1771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23052 ALICIA PKWY # 619
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92692-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-808-9797
-----------------------------------------------------
Fax | 714-808-9393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GIUSEPPE AMMIRATI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 858-677-1755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G88237
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------