1639119050 NPI number — OPHTHALMIC FACIAL PLASTIC SURGERY INSTITUTE A MEDICAL CORPORATION

Table of content: (NPI 1639119050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639119050 NPI number — OPHTHALMIC FACIAL PLASTIC SURGERY INSTITUTE A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPHTHALMIC FACIAL PLASTIC SURGERY INSTITUTE A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider's Other Name Information

Provider Other Organization Name:
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NPI Number Information

NPI Number:
1639119050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9735 WILSHIRE BLVD.
Provider Second Line Business Mailing Address:
STE 319
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90212-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-276-0044
Provider Business Mailing Address Fax Number:
310-271-7003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W BASTANCHURY RD
Provider Second Line Business Practice Location Address:
SUITE 191
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-3419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-449-1940
Provider Business Practice Location Address Fax Number:
714-449-1988
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERGER
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-449-1940

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  WG62027I , 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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