Healthcare Provider Details

I. General information

NPI: 1669886388
Provider Name (Legal Business Name): BEVERLY HILLS DERMATOLOGY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 N CAMDEN DR STE 805
BEVERLY HILLS CA
90210-4412
US

IV. Provider business mailing address

433 N CAMDEN DR STE 805
BEVERLY HILLS CA
90210-4412
US

V. Phone/Fax

Practice location:
  • Phone: 310-550-7661
  • Fax: 310-550-1920
Mailing address:
  • Phone: 310-550-7661
  • Fax: 310-550-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. LETANTIA BUSSELL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-550-7661