Provider Demographics
NPI:1053329540
Name:UROLOGY INSTITUTE OF THE SOUTH BAY
Entity Type:Organization
Organization Name:UROLOGY INSTITUTE OF THE SOUTH BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKAZAWA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:310-534-8400
Mailing Address - Street 1:23600 TELO AVE # 220
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4035
Mailing Address - Country:US
Mailing Address - Phone:310-534-8400
Mailing Address - Fax:310-534-0463
Practice Address - Street 1:23600 TELO AVE # 220
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4035
Practice Address - Country:US
Practice Address - Phone:310-534-8400
Practice Address - Fax:310-534-0463
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKYLINE UROLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11165OtherMEDICARE PTAN