Healthcare Provider Details

I. General information

NPI: 1700114303
Provider Name (Legal Business Name): ADVANCED SKINCARE SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 07/13/2011
Certification Date: ADVANCED SKINCARE SURGERY CENTER 301 W BASTANCHURY RD FULLERTON CA 92835 301 W BASTANCHURY RD FULLERTON CA 92835
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BASTANCHURY RD SUITE 240
FULLERTON CA
92835-3419
US

IV. Provider business mailing address

301 W BASTANCHURY RD SUITE 215
FULLERTON CA
92835-3419
US

V. Phone/Fax

Practice location:
  • Phone: 714-879-9936
  • Fax: 714-879-3035
Mailing address:
  • Phone: 714-879-9936
  • Fax: 714-879-3035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical
License NumberC1202500
License Number StateCA

VIII. Authorized Official

Name: MICHAEL SCHULTZ
Title or Position: BILLING DIRECTOR
Credential:
Phone: 714-879-9936