1033359930 NPI number — SYNERGY LASER CENTERS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033359930 NPI number — SYNERGY LASER CENTERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNERGY LASER CENTERS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033359930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15550 ROCKFIELD BLVD
Provider Second Line Business Mailing Address:
B220
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-598-9999
Provider Business Mailing Address Fax Number:
949-598-9990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 DIABLO RD
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94526-3430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-516-5855
Provider Business Practice Location Address Fax Number:
925-820-2094
Provider Enumeration Date:
03/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
925-516-5855

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC25600 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC25600 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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