Provider Demographics
NPI:1093959900
Name:CRANIOFACIAL/CLEFT PALATE PROGRAM
Entity Type:Organization
Organization Name:CRANIOFACIAL/CLEFT PALATE PROGRAM
Other - Org Name:CLEFT PALATE PROGRAM MEDICAL PRACTICE GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PLASTIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:LIBBY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:213-742-1433
Mailing Address - Street 1:403 W ADAMS BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-2664
Mailing Address - Country:US
Mailing Address - Phone:213-742-1433
Mailing Address - Fax:213-742-1496
Practice Address - Street 1:403 W ADAMS BLVD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2664
Practice Address - Country:US
Practice Address - Phone:213-742-1433
Practice Address - Fax:213-742-1496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty