Healthcare Provider Details

I. General information

NPI: 1912898909
Provider Name (Legal Business Name): SERGEY SUVOROV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9465 WILSHIRE BLVD STE 300
BEVERLY HILLS CA
90212-2624
US

IV. Provider business mailing address

6201 HOLLYWOOD BLVD UNIT 3618
LOS ANGELES CA
90028-6089
US

V. Phone/Fax

Practice location:
  • Phone: 424-261-9274
  • Fax:
Mailing address:
  • Phone: 424-261-9274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number92023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: