Provider Demographics
NPI:1053545905
Name:SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER
Entity type:Organization
Organization Name:SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NICCOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-3914
Mailing Address - Street 1:1101 BAYSIDE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1754
Mailing Address - Country:US
Mailing Address - Phone:949-718-6900
Mailing Address - Fax:
Practice Address - Street 1:1101 BAYSIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1702
Practice Address - Country:US
Practice Address - Phone:949-718-6900
Practice Address - Fax:949-718-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1929OtherPTAN