Provider Demographics
NPI:1710385901
Name:CITY OF ANGELS DERMATOLOGY INC
Entity Type:Organization
Organization Name:CITY OF ANGELS DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-651-8240
Mailing Address - Street 1:4712 ADMIRALTY WAY # 665
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:562-366-0300
Mailing Address - Fax:562-366-7525
Practice Address - Street 1:2888 LONG BEACH BLVD STE 325
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-7503
Practice Address - Country:US
Practice Address - Phone:562-366-0300
Practice Address - Fax:562-366-7525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-20
Last Update Date:2014-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLM 000346987291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory