Provider Demographics
NPI:1699711556
Name:ESCNC LLC
Entity type:Organization
Organization Name:ESCNC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUJAHID
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-723-7400
Mailing Address - Street 1:75 ENTERPRISE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2626
Mailing Address - Country:US
Mailing Address - Phone:949-688-6205
Mailing Address - Fax:949-688-6205
Practice Address - Street 1:1386 LEAD HILL BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2936
Practice Address - Country:US
Practice Address - Phone:916-723-7400
Practice Address - Fax:916-723-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000363261QA1903X, 261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR51040HMedicaid
CAZZZ18682ZMedicare PIN