=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689324758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRACLE SURGERY CENTER,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2022
-----------------------------------------------------
Last Update Date | 03/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2080 CENTURY PARK EAST SUITE 606
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-274-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2080 CENTURY PARK EAST SUITE 606
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-274-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. FARZIN KERENDIAN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 310-274-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------