Provider Demographics
NPI:1538178256
Name:MED-LASER SURGICAL CENTER LLC
Entity type:Organization
Organization Name:MED-LASER SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/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 1:2446 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3041
Mailing Address - Country:US
Mailing Address - Phone:323-728-5500
Mailing Address - Fax:323-728-4408
Practice Address - Street 1:2445 W WHITTIER BLVD
Practice Address - Street 2:SUITE #100
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3069
Practice Address - Country:US
Practice Address - Phone:323-727-2550
Practice Address - Fax:323-727-2552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000999261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051630Medicare ID - Type Unspecified