Healthcare Provider Details

I. General information

NPI: 1356785299
Provider Name (Legal Business Name): CALABASAS MEDICAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23659 CALABASAS RD
CALABASAS CA
91302-1502
US

IV. Provider business mailing address

23659 CALABASAS RD
CALABASAS CA
91302-1502
US

V. Phone/Fax

Practice location:
  • Phone: 818-850-7905
  • Fax: 818-225-8866
Mailing address:
  • Phone: 818-850-7905
  • Fax: 818-225-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA101945
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberG51360
License Number StateCA

VIII. Authorized Official

Name: JEFF ROBBINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 818-850-7905