Provider Demographics
NPI:1225227333
Name:SOUTHERN CALIFORNIA SKIN AND LASER
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA SKIN AND LASER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-707-5734
Mailing Address - Street 1:22972 MOULTON PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1219
Mailing Address - Country:US
Mailing Address - Phone:949-707-5734
Mailing Address - Fax:949-707-1924
Practice Address - Street 1:22972 MOULTON PKWY STE 106
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1219
Practice Address - Country:US
Practice Address - Phone:949-707-5734
Practice Address - Fax:949-707-1924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68285174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty