1245264753 NPI number — BEVERLY HILLS DERMATOLOGY CENTER

Table of content: (NPI 1073536215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245264753 NPI number — BEVERLY HILLS DERMATOLOGY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEVERLY HILLS DERMATOLOGY 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:
1245264753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 15807
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-860-7600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 N CAMDEN DRIVE #775
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-271-3354
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORTICH
Authorized Official First Name:
JOY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
909-860-7600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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