1598136384 NPI number — DIAMOND BAR DERMATOLOGY AND LASER CENTER

Table of content: (NPI 1598136384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598136384 NPI number — DIAMOND BAR DERMATOLOGY AND LASER CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAMOND BAR DERMATOLOGY AND LASER CENTER
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:
1598136384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
675 S ARROYO PKWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-844-3884
Provider Business Mailing Address Fax Number:
626-844-3886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
DIAMOND BAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91765-4171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-860-4254
Provider Business Practice Location Address Fax Number:
909-860-2674
Provider Enumeration Date:
10/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RIGOR
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
626-844-3884

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  A92405 , 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)





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