=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003857434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY VITA MEDICAL CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 04/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18607 VENTURA BLVD., SUITE 206
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-758-8282
-----------------------------------------------------
Fax | 818-758-8286
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18607 VENTURA BLVD., SUITE 206
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-758-8282
-----------------------------------------------------
Fax | 818-758-8286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | YUZEF GUROVICH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 805-910-0333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------