Provider Demographics
NPI:1265676993
Name:SKIN CANCER AND RECONSTRUCTIVE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SKIN CANCER AND RECONSTRUCTIVE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MADORSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-200-1600
Mailing Address - Street 1:180 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 157
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-6972
Mailing Address - Country:US
Mailing Address - Phone:949-200-1600
Mailing Address - Fax:949-200-1610
Practice Address - Street 1:180 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 157
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-6972
Practice Address - Country:US
Practice Address - Phone:949-200-1600
Practice Address - Fax:949-200-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical