Providence Specialty Surgery Center LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

PROVIDENCE SPECIALTY SURGERY CENTER LLC

Practice address

1310 W Stewart Dr Ste 310
Orange, CA 92868-3838

Phone

(714) 204-0444

NPI assigned

Apr 28, 2023

Organization subpart

No

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

Authorized official

Name

Mr. Jamshid Shadjareh

Title

Chairman, Governing Body

Phone

(714) 204-0444

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Ambulatory surgical center certification: CCN 55C0001194

Legal name

Providence Specialty Surgery Center

Certification status

Active

Provider type (POS)

Ambulatory surgical center

Participating since

Aug 12, 2025

Last certification

Aug 12, 2025

Facility address

1310 W Stewart Dr, Ste 310
Orange, CA 92868

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

CLIA laboratory certificates

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Homan Mahallati, D.O.

  • Family Medicine Physician
  • Pomona, CA
  • NPI 1215180765
  NPD (past)

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

{
    "created_epoch": "1682640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682640000000",
    "number": "1861180671",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1310 W STEWART DR STE 310",
            "city": "ORANGE",
            "state": "CA",
            "postal_code": "928683838",
            "telephone_number": "714-204-0444"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1310 W STEWART DR STE 310",
            "city": "ORANGE",
            "state": "CA",
            "postal_code": "928683838",
            "telephone_number": "714-204-0444"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE SPECIALTY SURGERY CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-04-28",
        "last_updated": "2023-04-28",
        "certification_date": "2023-04-28",
        "status": "A",
        "authorized_official_last_name": "SHADJAREH",
        "authorized_official_first_name": "JAMSHID",
        "authorized_official_title_or_position": "CHAIRMAN, GOVERNING BODY",
        "authorized_official_telephone_number": "714-204-0444",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Reagan Prospero
• Carolyn Elayne Protter, CNM
• Ernest Proud Jr., PH.D.
• Providence - Cardiology
• Providence Medical Foundation
• Providence Speech & Hearing Center
• Providence Speech and Hearing Center
• Providence Speech and Hearing Center
• Providence Speech and Hearing Center
• Alma Prudencio

• Ambulatory Surgical Clinic/Center in Orange, CA
• Providers in Orange, 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 Apr 28, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• 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.