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General NPI Number Information
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NPI Number | 1336648500
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Entity Type | Organization
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Legal Business Name | PRISTINE SURGICAL INCORPORATED
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Dates
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Enumeration Date | 02/02/2018
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Last Update Date | 03/10/2020
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Provider Practice Location Address
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Address Line | 6699 ALVARADO RD STE 2309
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City | SAN DIEGO
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State | CA
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Zip | 92120-5241
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Country | US
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Telephone | 619-396-6637
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Fax | 619-825-3406
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Provider Business Mailing Address
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Address Line | 7905 TOMMY DR
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City | SAN DIEGO
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State | CA
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Zip | 92119-1833
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | VADIM AVULOV
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Credential | DO
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Telephone | 917-602-4507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 20A13344
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License Number State | CA
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