=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851695860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SURGERY CENTER ON SAND CANYON SHADY CANYON EXIT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2011
-----------------------------------------------------
Last Update Date | 01/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16300 SAND CANYON AVE SUITE 901
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-677-9695
-----------------------------------------------------
Fax | 949-453-8601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16300 SAND CANYON AVE SUITE 901
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-677-9695
-----------------------------------------------------
Fax | 949-453-8601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. ALBERT BEOMJIN CHANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-585-9870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------