Provider Demographics
NPI:1053391169
Name:ENDOSCOPY CENTER OF THE SOUTH BAY LP
Entity type:Organization
Organization Name:ENDOSCOPY CENTER OF THE SOUTH BAY LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:23560 MADISON ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4709
Mailing Address - Country:US
Mailing Address - Phone:310-325-6331
Mailing Address - Fax:310-325-6335
Practice Address - Street 1:23560 MADISON ST
Practice Address - Street 2:SUITE 109
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4709
Practice Address - Country:US
Practice Address - Phone:310-325-6331
Practice Address - Fax:310-325-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000465261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31558ZMedicaid
CAS051211Medicare PIN
CA490005772Medicare PIN
CAZZZ31558ZMedicaid