=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669414306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEDOM VISION SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 10/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16255 VENTURA BLVD #100
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-783-2346
-----------------------------------------------------
Fax | 818-783-5048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16255 VENTURA BLVD #100
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-783-2346
-----------------------------------------------------
Fax | 818-783-5048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. KIM LYNCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-788-2346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 930000916
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------