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NPI Code Detail

MEDICARE: BLUE WAVE SURGICAL CENTER, INC.

MEDICARE: BLUE WAVE SURGICAL CENTER, INC.
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
1207Q00000XFamily Medicine PhysicianA54193CA

General Provider Information

NPI Number : 1770840100
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLUE WAVE SURGICAL CENTER, INC.
Provider Business Mailing Address
First Line : 4910 VAN NUYS BLVD STE 306
Second Line :
City : SHERMAN OAKS
State : CA
Zip : 91403-1770
Country : US
Telephone Number : 818-986-9918
Fax Number :
Provider Business Practice Location Address
First Line : 25043 NARBONNE AVE # A
Second Line :
City : LOMITA
State : CA
Zip : 90717-2101
Country : US
Telephone Number : 818-986-9918
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. ALEXANDER SOROKURS
Credential : M.D.
Telephone Number : 310-622-5369
Provider Enumeration Date : 04/23/2012
Last Update Date : 04/23/2012

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Directions to “BLUE WAVE SURGICAL CENTER, INC. ” Practice Location

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