Provider Demographics
NPI:1366629800
Name:DERMATOLOGY & COSMETIC CARE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DERMATOLOGY & COSMETIC CARE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RACKOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-497-8080
Mailing Address - Street 1:425 HAALAND DR.
Mailing Address - Street 2:SUITE # 204
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361
Mailing Address - Country:US
Mailing Address - Phone:805-497-8080
Mailing Address - Fax:805-497-8806
Practice Address - Street 1:425 HAALAND DR.
Practice Address - Street 2:SUITE #204
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:805-497-8080
Practice Address - Fax:805-497-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73488207N00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty