Provider Demographics
NPI:1831177567
Name:DE ANZA SURGERY CENTER
Entity type:Organization
Organization Name:DE ANZA SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:TENNANT
Authorized Official - Suffix:
Authorized Official - Credentials:CASC
Authorized Official - Phone:951-320-7799
Mailing Address - Street 1:4444 MAGNOLIA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4136
Mailing Address - Country:US
Mailing Address - Phone:951-320-7799
Mailing Address - Fax:951-274-3550
Practice Address - Street 1:4444 MAGNOLIA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4136
Practice Address - Country:US
Practice Address - Phone:951-320-7799
Practice Address - Fax:951-274-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250000795261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05C0001622Medicare ID - Type UnspecifiedASC