Source Surgery Center LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

SOURCE SURGERY CENTER LLC

Practice address

2801 Wilshire Blvd
Santa Monica, CA 90403-4801

Phone

(310) 574-2777

Fax

(310) 315-4968

NPI assigned

Mar 14, 2017

Last updated

Jan 21, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Timothy T Davis, MDNPI 1770515603

Title

Owner

Phone

(310) 574-2777

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Listed as

Source Surgery Center LLCCCN 05C0002218

Medicare certification status

ActiveFrom the Provider of Services file

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jungjae Lim, M.D.

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Granada Hills, CA
  • NPI 1689029563
  Medicare reassignment NPD
• Timothy T Davis, M.D.

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Santa Monica, CA
  • NPI 1770515603
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1489449600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1579564800000",
    "number": "1558802249",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1112 MONTANA AVE",
            "address_2": "SUITE 900",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904031652",
            "telephone_number": "310-574-2777",
            "fax_number": "310-315-4968"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2801 WILSHIRE BLVD",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904034801",
            "telephone_number": "310-574-2777",
            "fax_number": "310-315-4968"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOURCE SURGERY CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-14",
        "last_updated": "2020-01-21",
        "certification_date": "2020-01-21",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "310-574-2777",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Brian Jossue Sorto, DNP, AGACNP-BC
• Alexander Soto
• Melanie Anne Soto
• Soulaire Wellness
• Soultice Health Moves (Dr. Dorian R. Holmes)
• Cibele Sousa
• Southern California Head & Neck Medical Group
• Southern California Head & Neck Surgery Center
• Southern California Head Neck Imaging Center
• Southern California Medical Gastroenterology Group, Inc.

• Ambulatory Surgical Clinic/Center in Santa Monica, CA
• Providers in Santa Monica, CA by specialty
• Ambulatory Surgical Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.