MEDICARE: TOLUCA LAKE SURGICAL PARTNERS

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	:	1487252276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOLUCA LAKE SURGICAL PARTNERS

Provider Business Mailing Address
First Line	:	10876 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2236
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10876 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2236
Country	:	US
Telephone Number	:	818-821-3318
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN, GOVERNING
Name	:	MR. BORIS TRIPOLSKI
Credential	:
Telephone Number	:	818-821-3318

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	05/10/2021

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