=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922625995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL SURGICAL CENTERS STOCKTON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2020
-----------------------------------------------------
Last Update Date | 06/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 E HARDING WAY STE E
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95204-6118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-919-9560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 561 WINDING BROOK FARM RD
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-1747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-919-9560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF NURSING OFFICER
-----------------------------------------------------
Name | MRS. DIANE L BOONE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 312-919-9560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------