Provider Demographics
NPI:1912026097
Name:ADVANCED DERMATOLOGY & COSMETICS LASER CARE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY & COSMETICS LASER CARE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:I
Authorized Official - Last Name:RASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-254-3686
Mailing Address - Street 1:28212 KELLY JOHNSON PKWY
Mailing Address - Street 2:SUITE 245
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-5084
Mailing Address - Country:US
Mailing Address - Phone:661-254-3686
Mailing Address - Fax:661-254-5671
Practice Address - Street 1:28212 KELLY JOHNSON PKWY
Practice Address - Street 2:SUITE 245
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5084
Practice Address - Country:US
Practice Address - Phone:661-254-3686
Practice Address - Fax:661-254-5671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16330Medicare PIN
CAS051390Medicare PIN