Provider Demographics
NPI:1730452087
Name:IMPERIAL SURGICAL CENTRE LLC
Entity type:Organization
Organization Name:IMPERIAL SURGICAL CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVARO
Authorized Official - Middle Name:
Authorized Official - Last Name:LICEAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-770-8300
Mailing Address - Street 1:295 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1020
Mailing Address - Country:US
Mailing Address - Phone:714-770-8300
Mailing Address - Fax:
Practice Address - Street 1:295 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-1020
Practice Address - Country:US
Practice Address - Phone:714-770-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical