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General NPI Number Information
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NPI Number | 1770840100
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Entity Type | Organization
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Legal Business Name | BLUE WAVE SURGICAL CENTER, INC.
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Dates
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Enumeration Date | 04/23/2012
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Last Update Date | 04/23/2012
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Provider Practice Location Address
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Address Line | 25043 NARBONNE AVE # A
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City | LOMITA
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State | CA
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Zip | 90717-2101
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Country | US
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Telephone | 818-986-9918
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Fax |
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Provider Business Mailing Address
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Address Line | 4910 VAN NUYS BLVD STE 306
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City | SHERMAN OAKS
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State | CA
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Zip | 91403-1770
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Country | US
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Telephone | 818-986-9918
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALEXANDER SOROKURS
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Credential | M.D.
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Telephone | 310-622-5369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A54193
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License Number State | CA
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