MEDICARE: MAGNOLIA SURGERY CENTER, LLC

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

General Provider Information

NPI Number	:	1063887875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 181770
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92178-1770
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	463 N MAGNOLIA AVE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-3606
Country	:	US
Telephone Number	:	619-990-1698
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TAREK HASSANEIN
Credential	:
Telephone Number	:	619-990-1698

Provider Enumeration Date	:	12/04/2015
Last Update Date	:	05/04/2018

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