Provider Demographics
NPI:1811667264
Name:PRODERM IMAGE , A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:PRODERM IMAGE , A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-379-5970
Mailing Address - Street 1:960 S WESTLAKE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-3162
Mailing Address - Country:US
Mailing Address - Phone:805-379-5970
Mailing Address - Fax:805-379-5970
Practice Address - Street 1:960 S WESTLAKE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-3162
Practice Address - Country:US
Practice Address - Phone:805-379-5970
Practice Address - Fax:805-379-5970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty