1437402054 NPI number — PLASTICARE SURGERY CENTER LLC

Table of content: (NPI 1437402054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437402054 NPI number — PLASTICARE SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTICARE SURGERY CENTER LLC
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:
PLASTICARE SURGERY CENTER
Provider Other Organization Name Type Code:
4
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:
1437402054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 EAST WARDLOW ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90807-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-427-8944
Provider Business Mailing Address Fax Number:
562-427-4086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 EAST WARDLOW ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90807-4630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-427-8944
Provider Business Practice Location Address Fax Number:
562-427-4086
Provider Enumeration Date:
10/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JOY
Authorized Official First Name:
IKONIJA
Authorized Official Middle Name:
SEKULOVICH
Authorized Official Title or Position:
DIRECTOR PLASTICARE SURGERY CENTER
Authorized Official Telephone Number:
562-427-8944

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  G25370 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X , with the licence number: 1386(AAAASF) , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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