MEDICARE: NORTHWEST SURGICAL DEVELOPMENT OF PASADENA 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	:	1548651623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST SURGICAL DEVELOPMENT OF PASADENA LLC

Provider Business Mailing Address
First Line	:	65 ENTERPRISE
Second Line	:	STE 125
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-2706
Country	:	US
Telephone Number	:	949-600-9931
Fax Number	:	949-600-8029

Provider Business Practice Location Address
First Line	:	150 E COLORADO BLVD
Second Line	:	STE 102
City	:	PASADENA
State	:	CA
Zip	:	91105-1937
Country	:	US
Telephone Number	:	626-584-5898
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATION
Name	:	MR. JAMES HAEFNER
Credential	:
Telephone Number	:	949-600-9931

Provider Enumeration Date	:	02/11/2015
Last Update Date	:	02/11/2015

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