HomeMy WebLinkAbout9870 BRIMHALL ROAD #200' - ~ • Unidocs - Uniform Documents
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I. IDENTIFICATION
FACILITY ID#:
15 .;~ 021 _~~ 004000_ ` BEGINNING DATE (MM/DD/YYYY) ENDING DATE (MM/DD/YYW)
08/10/2008 ~ 08/10/2009 ___ _ __ _~
~ ~
BUSINESS PHONE (li##) llk#-li#riq
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) xk###
APPLE SURGERY CENTER _ ....................................: (661)615-1940
~~ ~
BUSINESS SITE ADDRESS:
9870 BRIMHALL ROAD SUITE 200 ~
_._.._..~......rr.____..~..~_..
._
.
...
~.
__
_._
__.
CITY: ~~__~_~......_. __._...~.~._..__~.w..__ _.~....~,_.~_.__.~
STATE: ZIP CODE:
BAKERSFIELD
.............._....,....~..__............__._.
..
.
. CA 93312 ~
,
....
.
.
............~................. ...._._..__..~................
DUN & BRADSTREET: ........... . _..__....__...... __............__....___.
SIC CODE (4 digit k):
TID 200182122 r
~
COUNTY: N~q_v~
KERN
BUSINESS OPERATOR NAME: ~~ BUSINESS OPERATOR PHONE: (##It) tIN#-~l#ttli xil###
NANAKUMAR RAVI ~ (661)615-1940 _____~
II. BUSINESS OWNER
OWNER NAME: OWNER PHONE: (#iiN) iilftf-#likti x#Nlitt
NANAKUMAR RAVI
_-_____~_....~......~_.._..._._._._..__ _ ~ ; (661) 472-0150 ~
... ............
OWNER MAILING ADDRESS: ..~ _ _.... ........
P O BOX 22500
CITY:
BAKERSFIELD
,.._.~ ......................................~.................... . STATE: ZIP CODE:
;
CA ' 93390-2500
........................,._..__.,.,,..,,_.............. W.x.....,....,...: F
III. ENVIRONMENTAL CONTACT
CONTACT NAME: CONTACT PHONE: (k!~#) #MN-Nl~HH
NANAKUMAR RAVI x#It#il
_.
_...._` 661 472-0150
~ . ....... ...... ._... ~ _
~
CONTACT MAILING ADDRESS:
P O BOX 22500
~ ~~~
~
CITY: STATE:
~ ~~ ~ mm ZIP CODE:
Bakersfield ~ CA '~ 93390-2500 ~
IV. EMERGENCY CONTACTS
-PRIMARY- -SECONDARY-
https://unidocs.ecointeractive.com/user/facility edit.asp?facility id=15-021-004000 12/3/2008
~•Unidocs - Uniform Documents
NAME:
NANAKUMAR RAVI
TITLE: ~
OWNER
BUSINESS PHONE: (MNtI) i!#JI-ilk#N x###N ~
(661)615-1940 '
_...~......_...~.~....._..__~
24-HOUR PHONE: (k#tl) ###-##k# x###~
(661)615-1934 ~ ;
PAGERk:
(661) 472-0510 ~ '
ADDITIONAL LOCALLY COLLECTED INFORMATION:
Page 2 of 2
NAME:
RAJEEV MANU
TITLE:
ADMINISTRATOR ;
BUSINESS PHONE: (#i!#) ~ilf#-Nii## xk##ri ~
(661)615-1940 ~
~ ................ _... _ _...................
24-HOUR PHONE: (#k#) il#tl-#N#i~ x{f#tlk
(661)322-2424 ~ ~
PAGERN:
(661) 477-6334 ~ ~~
Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penaltyof law
that I have personally examined and am familiar with the information submitted and believe the information is true, accurate,
and complete.
DATE: (MM/DD/YYYY)
~s/2~/2008
_______.w____ _ _.._ ..,.~._..w ...______~__~
NAME OF SIGNER:
NANAKUMAR RAVI M.D.
NAME OF DOCUMENT PREPARER:
JENNY ROSALES '
_.......~ ~ , ~ ~.__.._ ~~.._ __~_........__.~_ ~
TITLE OF SIGNER:
OWNER
UPCF(1/99 revised)
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