Provider Demographics
NPI:1609052893
Name:CALIFORNIA INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY A MED. CORP
Entity Type:Organization
Organization Name:CALIFORNIA INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY A MED. CORP
Other - Org Name:CHANGES PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-720-1440
Mailing Address - Street 1:11515 EL CAMINO REAL STE 150
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3037
Mailing Address - Country:US
Mailing Address - Phone:858-720-1440
Mailing Address - Fax:858-509-7738
Practice Address - Street 1:11515 EL CAMINO REAL STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3037
Practice Address - Country:US
Practice Address - Phone:858-720-1440
Practice Address - Fax:858-509-7738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63907261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF65386Medicare UPIN
CAW13535Medicare PIN