Provider Demographics
NPI:1558440529
Name:BRUCE ROLSTON
Entity type:Organization
Organization Name:BRUCE ROLSTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-884-9944
Mailing Address - Street 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:#440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-471-5852
Mailing Address - Fax:310-471-3958
Practice Address - Street 1:7325 MEDICAL CENTER DR
Practice Address - Street 2:#103
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1925
Practice Address - Country:US
Practice Address - Phone:818-884-9944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO047AMedicare PIN