Provider Demographics
NPI:1841892965
Name:SOROYA BACCHUS, MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:SOROYA BACCHUS, MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOROYA
Authorized Official - Middle Name:MONTEZ
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-895-2541
Mailing Address - Street 1:6801 PARK TER STE 530B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:310-895-2541
Mailing Address - Fax:310-895-2895
Practice Address - Street 1:6801 PARK TER STE 530B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-895-2541
Practice Address - Fax:310-895-2895
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOROYA BACCHUS, MD A PROFESSIONAL MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty