MEDICARE: BAKERSFIELD LITHOTRIPSY, 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	:	1427236397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAKERSFIELD LITHOTRIPSY, LLC

Provider Business Mailing Address
First Line	:	6339 E SPEEDWAY BLVD
Second Line	:	SUITE 201
City	:	TUCSON
State	:	AZ
Zip	:	85710-1147
Country	:	US
Telephone Number	:	520-547-4130
Fax Number	:	520-258-0304

Provider Business Practice Location Address
First Line	:	2202 S FIGUEROA ST
Second Line	:	#6001
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-2049
Country	:	US
Telephone Number	:	520-547-4130
Fax Number	:	520-258-0304

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER OF ABS
Name	:	LACEY DINH
Credential	:
Telephone Number	:	520-258-0326

Provider Enumeration Date	:	02/04/2008
Last Update Date	:	12/16/2015

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