=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619685153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINTSUGI SURGICAL II LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2022
-----------------------------------------------------
Last Update Date | 11/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 WILSHIRE BLVD STE 1000
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-328-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 WILSHIRE BLVD STE 1000
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-328-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING ASSOCIATE GENERAL COUNSEL
-----------------------------------------------------
Name | CHRISTOPHER DOAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-259-4706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------