Provider Demographics
NPI:1740447044
Name:REJUVENATION SURGICENTER
Entity type:Organization
Organization Name:REJUVENATION SURGICENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SID
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMRAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-783-5058
Mailing Address - Street 1:17525 VENTURA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:818-783-5059
Practice Address - Street 1:17525 VENTURA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3843
Practice Address - Country:US
Practice Address - Phone:818-783-5050
Practice Address - Fax:818-783-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP36955261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical