Provider Demographics
NPI:1437567765
Name:CONEJO VALLEY OUTPATIENT CENTER, LLC
Entity type:Organization
Organization Name:CONEJO VALLEY OUTPATIENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-846-4155
Mailing Address - Street 1:PO BOX 881840
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-3013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:310-846-4155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical