Basic Information
| Provider Information | |||||||||
| NPI: | 1689324758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRACLE SURGERY CENTER, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 CENTURY PARK EAST | ||||||||
| Address2: | SUITE 606 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102744900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2080 CENTURY PARK EAST | ||||||||
| Address2: | SUITE 606 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102744900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | KERENDIAN | ||||||||
| AuthorizedOfficialFirstName: | FARZIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3102744900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.