Healthcare Provider Details

I. General information

NPI: 1003090978
Provider Name (Legal Business Name): MODERN INTITUTE OF PLASTIC SURGERY & ANTI-AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9090 BURTON WAY
BEVERLY HILLS CA
90211-1661
US

IV. Provider business mailing address

9090 BURTON WAY
BEVERLY HILLS CA
90211-1661
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-0077
  • Fax:
Mailing address:
  • Phone: 310-278-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberC2780128
License Number StateCA

VIII. Authorized Official

Name: DR. RYAN A. STANTON
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-278-0077