Healthcare Provider Details

I. General information

NPI: 1417496738
Provider Name (Legal Business Name): BIXBY LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 ATLANTIC AVE
LONG BEACH CA
90807-3418
US

IV. Provider business mailing address

3650 ATLANTIC AVE
LONG BEACH CA
90807-3418
US

V. Phone/Fax

Practice location:
  • Phone: 562-896-4809
  • Fax:
Mailing address:
  • Phone: 562-896-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANNA GEVORGYAN
Title or Position: OWNER
Credential: M.D.
Phone: 562-896-4809