MEDICARE: PASADENA AMBULATORY SURGERY CENTER

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	:	1508948787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASADENA AMBULATORY SURGERY CENTER

Provider Business Mailing Address
First Line	:	11999 SAN VICENTE BLVD
Second Line	:	#440
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-5131
Country	:	US
Telephone Number	:	310-471-5852
Fax Number	:	310-471-3958

Provider Business Practice Location Address
First Line	:	301 S FAIR OAKS AVE
Second Line	:	#106
City	:	PASADENA
State	:	CA
Zip	:	91105-2561
Country	:	US
Telephone Number	:	626-440-0099
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WILLIAM FREDERICK STEPHENS
Credential	:	D.D.S.
Telephone Number	:	626-440-0099

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	08/22/2020

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