MEDICARE: PALM VALLEY SURGICAL 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

General Provider Information

NPI Number	:	1316440811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM VALLEY SURGICAL CENTER, INC

Provider Business Mailing Address
First Line	:	12277 APPLE VALLEY RD PMB 397
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-1701
Country	:	US
Telephone Number	:	760-810-7587
Fax Number	:	760-810-7593

Provider Business Practice Location Address
First Line	:	72650 FRED WARING DR STE 103
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-5007
Country	:	US
Telephone Number	:	760-810-7587
Fax Number	:	760-810-7593

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	DIANE MICHELLE SOTO
Credential	:
Telephone Number	:	760-375-3974

Provider Enumeration Date	:	03/12/2018
Last Update Date	:	03/12/2018

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