1669977021 NPI number — SHONAN BEAUTY CLINIC BEVERLY HILLS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669977021 NPI number — SHONAN BEAUTY CLINIC BEVERLY HILLS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHONAN BEAUTY CLINIC BEVERLY HILLS, 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:
SHONAN BEAUTY CLINIC SURGERY CENTER
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:
1669977021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 HAALAND DRIVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91361-5229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-723-8008
Provider Business Mailing Address Fax Number:
805-852-2675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 HAALAND DRIVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91361-5229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-723-8008
Provider Business Practice Location Address Fax Number:
805-852-2675
Provider Enumeration Date:
03/28/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
805-723-8008

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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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