1023150018 NPI number — EARL PLASTIC SURGERY, P.C.

Table of content: (NPI 1023150018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023150018 NPI number — EARL PLASTIC SURGERY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EARL PLASTIC SURGERY, P.C.
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:
1023150018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
653 N TOWN CENTER DR
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89144-0514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-939-3436
Provider Business Mailing Address Fax Number:
702-939-3437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
653 N TOWN CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89144-0514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-939-3436
Provider Business Practice Location Address Fax Number:
702-939-3437
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EARL
Authorized Official First Name:
CAMERON
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-939-3436

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  11812 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11391671 . This is a "CAQH NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1740269703 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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