Healthcare Provider Details

I. General information

NPI: 1912371352
Provider Name (Legal Business Name): ENT SURGICAL SPECIALISTS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6424 W OLYMPIC BLVD
LOS ANGELES CA
90048-5347
US

IV. Provider business mailing address

6424 W OLYMPIC BLVD
LOS ANGELES CA
90048-5347
US

V. Phone/Fax

Practice location:
  • Phone: 310-772-2866
  • Fax: 310-421-1880
Mailing address:
  • Phone: 310-772-2866
  • Fax: 310-421-1880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberA112498
License Number StateCA

VIII. Authorized Official

Name: NEDA NAZARIAN
Title or Position: DIRECTOR OF OPERATION
Credential:
Phone: 310-772-2866