1942225255 NPI number — CENTER FOR FACIAL APPEARANCE, PC

Table of content: (NPI 1942225255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942225255 NPI number — CENTER FOR FACIAL APPEARANCE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR FACIAL APPEARANCE, PC
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:
1942225255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 E SOUTH TEMPLE
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84102-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-363-3355
Provider Business Mailing Address Fax Number:
801-533-9613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-844-3223
Provider Business Practice Location Address Fax Number:
801-533-9613
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCANN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
801-363-3355

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  A51131 , 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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