Provider Demographics
NPI:1437402054
Name:PLASTICARE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PLASTICARE SURGERY CENTER LLC
Other - Org Name:PLASTICARE SURGERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR PLASTICARE SURGERY CENTER
Authorized Official - Prefix:
Authorized Official - First Name:IKONIJA
Authorized Official - Middle Name:SEKULOVICH
Authorized Official - Last Name:JOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-427-8944
Mailing Address - Street 1:920 EAST WARDLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-4630
Mailing Address - Country:US
Mailing Address - Phone:562-427-8944
Mailing Address - Fax:562-427-4086
Practice Address - Street 1:920 EAST WARDLOW ROAD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4630
Practice Address - Country:US
Practice Address - Phone:562-427-8944
Practice Address - Fax:562-427-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25370208200000X
IL1386(AAAASF)261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty