MEDICARE: CENTENNIAL SPECIALTY SURGERY CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	20120078160-37	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20120078160-37	OTHER	NV	CORPORATION ID

General Provider Information

NPI Number	:	1043560295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTENNIAL SPECIALTY SURGERY CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 16297
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90209-2297
Country	:	US
Telephone Number	:	800-991-6448
Fax Number	:

Provider Business Practice Location Address
First Line	:	5550 PAINTED MIRAGE RD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4581
Country	:	US
Telephone Number	:	310-993-8994
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL P TAHERI
Credential	:	M.D.
Telephone Number	:	310-993-8994

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	08/07/2020

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