Provider Demographics
NPI:1811510043
Name:KODRICH, MICHAEL J (ELECTROLOGIST)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:KODRICH
Suffix:
Gender:M
Credentials:ELECTROLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 MONTECITO DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3222
Mailing Address - Country:US
Mailing Address - Phone:714-383-0983
Mailing Address - Fax:
Practice Address - Street 1:15051 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2710
Practice Address - Country:US
Practice Address - Phone:714-642-4622
Practice Address - Fax:714-642-4622
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9658174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty