Provider Demographics
NPI:1124068549
Name:CROWN VALLEY SURGERY CENTER
Entity type:Organization
Organization Name:CROWN VALLEY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIMISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:949-348-7252
Mailing Address - Street 1:26921 CROWN VALLEY PKWY
Mailing Address - Street 2:110
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6501
Mailing Address - Country:US
Mailing Address - Phone:949-348-7252
Mailing Address - Fax:949-348-7675
Practice Address - Street 1:26921 CROWN VALLEY PKWY
Practice Address - Street 2:110
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6501
Practice Address - Country:US
Practice Address - Phone:949-348-7252
Practice Address - Fax:949-348-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2007-09-28
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
CAS051355Medicare PIN