Provider Demographics
NPI:1902234230
Name:MAINBRIDGE SURGERY CENTER INC.
Entity Type:Organization
Organization Name:MAINBRIDGE SURGERY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-771-9252
Mailing Address - Street 1:400 E RINCON ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1389
Mailing Address - Country:US
Mailing Address - Phone:714-771-9252
Mailing Address - Fax:714-771-8481
Practice Address - Street 1:400 E RINCON ST
Practice Address - Street 2:SUITE 107
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1389
Practice Address - Country:US
Practice Address - Phone:714-771-9252
Practice Address - Fax:714-771-8481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45605261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical