Healthcare Provider Details

I. General information

NPI: 1447077177
Provider Name (Legal Business Name): PACIFIC SHORES DERMATOLOGY & SKIN CANCER INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 OAK PARK BLVD STE 101
ARROYO GRANDE CA
93420-1800
US

IV. Provider business mailing address

PO BOX 2505
PISMO BEACH CA
93448-2505
US

V. Phone/Fax

Practice location:
  • Phone: 805-202-8245
  • Fax: 805-202-8117
Mailing address:
  • Phone: 805-202-8245
  • Fax: 805-202-8117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURA SANDOVAL
Title or Position: OWNER
Credential: DO
Phone: 760-217-1457