| NPI | 1790890085 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOY FORTICH Billing Manager 909-860-7600 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: CA G044761) |
| Additional Taxonomies | 207ND0900X Dermatology, Dermatopathology (Licence: CA G044761) |
| 207ND0101X Dermatology, MOHS-Micrographic Surgery (Licence: CA G044761) | |
| 207NP0225X Dermatology, Pediatric Dermatology (Licence: CA G044761) | |
| 207NS0135X Dermatology, Procedural Dermatology (Licence: CA G044761) | |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2010-01-13 |