MEDICARE: DISC SURGERY CENTER AT MARINA DEL REY 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	:	1750071007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISC SURGERY CENTER AT MARINA DEL REY LLC

Provider Business Mailing Address
First Line	:	4553 GLENCOE AVE STE 100
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-7917
Country	:	US
Telephone Number	:	949-988-7828
Fax Number	:

Provider Business Practice Location Address
First Line	:	4553 GLENCOE AVE STE 100
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-7917
Country	:	US
Telephone Number	:	949-988-7828
Fax Number	:	949-988-7869

Authorized Official
Title or Position	:	VP OPERATIONS AND PAYOR MANAGEMENT
Name	:	MRS. KAREN REITER
Credential	:
Telephone Number	:	949-988-7828

Provider Enumeration Date	:	05/10/2023
Last Update Date	:	05/10/2023

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