Provider Demographics
NPI:1750509444
Name:ALAMITOS DERMATOLOGICAL MEDICAL CLINIC A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:ALAMITOS DERMATOLOGICAL MEDICAL CLINIC A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:T
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-598-8593
Mailing Address - Street 1:3801 KATELLA AVE
Mailing Address - Street 2:SUITE 425
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3338
Mailing Address - Country:US
Mailing Address - Phone:562-598-8593
Mailing Address - Fax:562-594-0877
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:SUITE 425
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3338
Practice Address - Country:US
Practice Address - Phone:562-598-8593
Practice Address - Fax:562-594-0877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1155Medicare PIN