Basic Information
| Provider Information | |||||||||
| NPI: | 1114380706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEVERLY HILLS PREMIUM SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 N LA CIENEGA BLVD # 102A | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902112222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103607368 | ||||||||
| FaxNumber: | 3103607370 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 N LA CIENEGA BLVD # 102A | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902112222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103607368 | ||||||||
| FaxNumber: | 3103607370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | SHKLYARENKO | ||||||||
| AuthorizedOfficialFirstName: | BELLA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3103607368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.