=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649471061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA ADVANCED LAPARO ENDOSCOPIC SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 ROLLING OAKS DR SUITE 240
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-230-0030
-----------------------------------------------------
Fax | 805-306-1849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 ROLLING OAKS DR SUITE 240
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-230-0030
-----------------------------------------------------
Fax | 805-306-1849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DINA CARDILINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-306-1849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------