Healthcare Provider Details

I. General information

NPI: 1700112216
Provider Name (Legal Business Name): LA SKINCARE CENTER A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2284 E. MAPLE AVE
EL SEGUNDO CA
90245
US

IV. Provider business mailing address

2284 E MAPLE AVE
EL SEGUNDO CA
90245-6507
US

V. Phone/Fax

Practice location:
  • Phone: 310-414-9761
  • Fax: 310-414-9765
Mailing address:
  • Phone: 310-414-9761
  • Fax: 310-414-9765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberG24428
License Number StateCA

VIII. Authorized Official

Name: RAISA HOWARD
Title or Position: OWNER
Credential: C.N.P
Phone: 310-414-9730