Provider Demographics
NPI:1639651011
Name:HEAVENLY PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:HEAVENLY PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-980-3715
Mailing Address - Street 1:29300 PORTOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8718
Mailing Address - Country:US
Mailing Address - Phone:657-333-5497
Mailing Address - Fax:
Practice Address - Street 1:29300 PORTOLA PKWY
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8718
Practice Address - Country:US
Practice Address - Phone:657-333-5497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty