Provider Demographics
NPI:1306017801
Name:BRIAN J. EICHENBERG, M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRIAN J. EICHENBERG, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:RENUANCE COSMETIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:EICHENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-506-1040
Mailing Address - Street 1:24687 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9591
Mailing Address - Country:US
Mailing Address - Phone:951-506-1040
Mailing Address - Fax:951-506-1044
Practice Address - Street 1:24687 MONROE AVE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9591
Practice Address - Country:US
Practice Address - Phone:951-506-1040
Practice Address - Fax:951-506-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55426208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A554260Medicaid