Provider Demographics
NPI:1780642967
Name:WOODGLEN INSTITUTE OF AESTHETICS AND DERMATOLOGY
Entity Type:Organization
Organization Name:WOODGLEN INSTITUTE OF AESTHETICS AND DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:EMRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-963-4124
Mailing Address - Street 1:541 S PASADENA AVE
Mailing Address - Street 2:201
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-6232
Mailing Address - Country:US
Mailing Address - Phone:626-852-0599
Mailing Address - Fax:626-852-0010
Practice Address - Street 1:541 S PASADENA AVE
Practice Address - Street 2:201
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-6232
Practice Address - Country:US
Practice Address - Phone:626-852-0599
Practice Address - Fax:626-852-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19284Medicare ID - Type UnspecifiedGROUP ID NUMBER