MEDICARE: MID-VALLEY 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
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1861923625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-VALLEY SURGICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	7640 TAMPA AVE
Second Line	:	SUITE 102
City	:	RESEDA
State	:	CA
Zip	:	91335-1700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7640 TAMPA AVE
Second Line	:	SUITE 102
City	:	RESEDA
State	:	CA
Zip	:	91335-1700
Country	:	US
Telephone Number	:	818-454-3638
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEO POLOSAJIAN
Credential	:	M.D.
Telephone Number	:	818-454-3638

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	03/23/2017

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