=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902234230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAINBRIDGE SURGERY CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2013
-----------------------------------------------------
Last Update Date | 10/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 E RINCON ST SUITE 107
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-1389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-771-9252
-----------------------------------------------------
Fax | 714-771-8481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 E RINCON ST SUITE 107
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-1389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-771-9252
-----------------------------------------------------
Fax | 714-771-8481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. LARRY WONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 714-771-9252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | G45605
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------