Provider Demographics
NPI:1083788038
Name:REGENTS OF UNIVERSITY OF CALIFORNIA SIMMS MANN UCLA
Entity Type:Organization
Organization Name:REGENTS OF UNIVERSITY OF CALIFORNIA SIMMS MANN UCLA
Other - Org Name:REFLECTIONS BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSCARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-794-9090
Mailing Address - Street 1:200 UCLA MEDICAL PLZ STE 163
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-6934
Mailing Address - Country:US
Mailing Address - Phone:310-794-9090
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 163
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6934
Practice Address - Country:US
Practice Address - Phone:310-794-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
116-289-0001Medicare ID - Type Unspecified