1386629905 NPI number — SOUTHERN CALIFORNIA DERMATOLOGY, INC

Table of content: (NPI 1386629905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386629905 NPI number — SOUTHERN CALIFORNIA DERMATOLOGY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CALIFORNIA DERMATOLOGY, INC
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:
6
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:
1386629905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 E 17TH ST
Provider Second Line Business Mailing Address:
W-248
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92701-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-547-5151
Provider Business Mailing Address Fax Number:
714-547-4027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 E 17TH ST
Provider Second Line Business Practice Location Address:
W-248
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92701-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-547-5151
Provider Business Practice Location Address Fax Number:
714-541-2016
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BARON
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-547-5151

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2025 www.npivalidator.com