1649310814 NPI number — RENAISSANCE CLINIQUE, PA

Table of content: (NPI 1649310814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649310814 NPI number — RENAISSANCE CLINIQUE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE CLINIQUE, PA
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:
CLINIQUE OF 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:
1649310814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11999 SAN VICENTE BLVD
Provider Second Line Business Mailing Address:
STE. 440
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90049-5131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-471-5852
Provider Business Mailing Address Fax Number:
310-471-3958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 ULMERTON RD
Provider Second Line Business Practice Location Address:
STE. 27
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33762-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-592-0991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DREHSEN
Authorized Official First Name:
CHRISTIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
727-592-0991

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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