Provider Demographics
NPI:1467607127
Name:TRILLIUM MED SPA COSMETIC SURGERY AND LASER CENTER
Entity Type:Organization
Organization Name:TRILLIUM MED SPA COSMETIC SURGERY AND LASER CENTER
Other - Org Name:MOORPARK WOMEN'S HEALTH & SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-597-9300
Mailing Address - Street 1:145 PARK LN STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2117
Mailing Address - Country:US
Mailing Address - Phone:805-531-9419
Mailing Address - Fax:805-531-9494
Practice Address - Street 1:145 PARK LN STE 200
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-2117
Practice Address - Country:US
Practice Address - Phone:805-531-9419
Practice Address - Fax:805-531-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-22
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
CAA103922261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty