MEDICARE: BONITA SURGICAL MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1144574815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONITA SURGICAL MEDICAL CENTER

Provider Business Mailing Address
First Line	:	221 N SAN DIMAS AVE
Second Line	:	STE 200
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-2664
Country	:	US
Telephone Number	:	909-592-0142
Fax Number	:	909-592-0339

Provider Business Practice Location Address
First Line	:	221 N SAN DIMAS AVE
Second Line	:	STE 200
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-2664
Country	:	US
Telephone Number	:	909-592-0142
Fax Number	:	909-592-0339

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	ALEXANDER SOROKURS
Credential	:	M.D.
Telephone Number	:	909-592-0142

Provider Enumeration Date	:	11/02/2012
Last Update Date	:	11/02/2012

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