Provider Demographics
NPI:1275768004
Name:SKIN CANCER&RECONSTRUCTIVE SX SPECIALISTS OF VALENCIA
Entity Type:Organization
Organization Name:SKIN CANCER&RECONSTRUCTIVE SX SPECIALISTS OF VALENCIA
Other - Org Name:SKIN CANCER&RECONSTRUCTIVE SX SPECIALISTS OF VALENCIA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OMIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-273-8849
Mailing Address - Street 1:9001 WILSHIRE BLVD
Mailing Address - Street 2:106
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1849
Mailing Address - Country:US
Mailing Address - Phone:310-273-8849
Mailing Address - Fax:866-664-7321
Practice Address - Street 1:9001 WILSHIRE BLVD
Practice Address - Street 2:106
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1838
Practice Address - Country:US
Practice Address - Phone:310-273-8849
Practice Address - Fax:866-664-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty