Healthcare Provider Details

I. General information

NPI: 1821362443
Provider Name (Legal Business Name): BLUE WAVE SURGERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 04/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 VAN NUYS BLVD STE 306
SHERMAN OAKS CA
91403-1770
US

IV. Provider business mailing address

4910 VAN NUYS BLVD STE 306
SHERMAN OAKS CA
91403-1770
US

V. Phone/Fax

Practice location:
  • Phone: 310-622-5369
  • Fax:
Mailing address:
  • Phone: 310-622-5369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA54193
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA54193
License Number StateCA

VIII. Authorized Official

Name: DR. ALEXANDER SOROKURS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-622-5369