Provider Demographics
NPI:1316949415
Name:NEWPORT BEACH SURGERY CENTER, LLC
Entity type:Organization
Organization Name:NEWPORT BEACH SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:TREY
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:949-631-0988
Mailing Address - Street 1:361 HOSPITAL ROAD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-631-0988
Mailing Address - Fax:949-631-2504
Practice Address - Street 1:361 HOSPITAL ROAD
Practice Address - Street 2:SUITE 124
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-631-0988
Practice Address - Fax:949-631-2504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-02
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000339261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA060000339OtherSTATE LICENSE
CA060000339OtherSTATE LICENSE