=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083877542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAKERSFIELD OUTPATIENT SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2008
-----------------------------------------------------
Last Update Date | 07/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 CHINA GRADE LOOP SUITE C
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93308-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-340-9910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 FIELDSPRING DR
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311-3576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-858-0865
-----------------------------------------------------
Fax | 661-858-0940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL & MAXILLOFACIAL SURGEON
-----------------------------------------------------
Name | DR. SERGE V VERNE
-----------------------------------------------------
Credential | D.D.S., M.D.
-----------------------------------------------------
Telephone | 661-865-4209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | 38144
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------