Provider Demographics
NPI:1033177373
Name:SURGICARE OF LA VETA LTD
Entity type:Organization
Organization Name:SURGICARE OF LA VETA LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSSANENENZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-278-0853
Mailing Address - Street 1:681 S PARKER ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4719
Mailing Address - Country:US
Mailing Address - Phone:714-744-0900
Mailing Address - Fax:
Practice Address - Street 1:681 S PARKER ST
Practice Address - Street 2:SUITE 150
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4719
Practice Address - Country:US
Practice Address - Phone:714-744-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051179Medicare PIN