1609052893 NPI number — CALIFORNIA INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY A MED. CORP

Table of content: (NPI 1609052893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609052893 NPI number — CALIFORNIA INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY A MED. CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY A MED. CORP
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:
CHANGES PLASTIC SURGERY
Provider Other Organization Name Type Code:
3
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:
1609052893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11515 EL CAMINO REAL STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92130-3037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-720-1440
Provider Business Mailing Address Fax Number:
858-509-7738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11515 EL CAMINO REAL STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-3037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-720-1440
Provider Business Practice Location Address Fax Number:
858-509-7738
Provider Enumeration Date:
01/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
GILBERT
Authorized Official Middle Name:
WESLEY
Authorized Official Title or Position:
PHYSICIAN / OWNER
Authorized Official Telephone Number:
858-720-1440

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  G63907 , 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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