=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982744231
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHLAND ENDOSCOPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 09/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 949 CALHOUN PL SUITE B
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-929-1177
-----------------------------------------------------
Fax | 951-765-9111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 949 CALHOUN PL SUITE B
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-929-1177
-----------------------------------------------------
Fax | 951-765-9111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D, F.A.C.P, F.A.C.G
-----------------------------------------------------
Name | DR. SREENIVASA R NAKKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-929-1177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 240000545
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------