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General NPI Number Information
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NPI Number | 1669975595
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Entity Type | Organization
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Legal Business Name | ELITE SURGICAL
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Dates
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Enumeration Date | 03/16/2018
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Last Update Date | 03/16/2018
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Provider Practice Location Address
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Address Line | 496 OLD NEWPORT BLVD STE 6
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-4264
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Country | US
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Telephone | 949-722-7662
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Fax | 949-631-6585
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Provider Business Mailing Address
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Address Line | 496 OLD NEWPORT BLVD STE 6
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-4264
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Country | US
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Telephone | 949-722-7662
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Fax | 949-631-6585
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Authorized Official
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Title or Position | OFFICE MGR
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Name | TAMMY POLIQUIN
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Credential |
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Telephone | 949-722-7662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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