# SOURCE SURGERY CENTER LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1558802249
- **Authorized official:** DR. TIMOTHY T DAVIS MD (OWNER)
- **Authorized official phone:** (310) 574-2777

## Contact information

- **Practice address:** 2801 WILSHIRE BLVD, SANTA MONICA, CA 90403-4801
- **Practice address phone:** (310) 574-2777
- **Practice address fax:** (310) 315-4968
- **Mailing address:** 1112 MONTANA AVE, SUITE 900, SANTA MONICA, CA 90403-1652
- **Mailing address phone:** (310) 574-2777
- **Mailing address fax:** (310) 315-4968

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 03/14/2017
- **Last updated:** 01/21/2020