MEDICARE: SOCAL BREATHE FREE ASC 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	:	1760141022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOCAL BREATHE FREE ASC LLC

Provider Business Mailing Address
First Line	:	201 S BUENA VISTA ST STE 300
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4580
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 S BUENA VISTA ST STE 300
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4580
Country	:	US
Telephone Number	:	520-979-6774
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TAYLOR BORANE
Credential	:
Telephone Number	:	520-979-6774

Provider Enumeration Date	:	12/14/2021
Last Update Date	:	12/14/2021

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