Provider Demographics
NPI:1497788145
Name:ENDOSCOPY CENTER OF SOUTHERN CALIFORNIA LLC
Entity type:Organization
Organization Name:ENDOSCOPY CENTER OF SOUTHERN CALIFORNIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:2336 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE #204
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2095
Mailing Address - Country:US
Mailing Address - Phone:310-829-6789
Mailing Address - Fax:310-315-0204
Practice Address - Street 1:2336 SANTA MONICA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2938
Practice Address - Country:US
Practice Address - Phone:310-453-4477
Practice Address - Fax:310-315-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01193FMedicaid
CAS051193Medicare ID - Type Unspecified