Healthcare Provider Details

I. General information

NPI: 1649698143
Provider Name (Legal Business Name): IMAGE PLASTIC SURGERY CENTER A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 CENTER AVE 201
HUNTINGTON BEACH CA
92647-9110
US

IV. Provider business mailing address

7801 CENTER AVE 201
HUNTINGTON BEACH CA
92647-9110
US

V. Phone/Fax

Practice location:
  • Phone: 714-230-2430
  • Fax: 714-230-2431
Mailing address:
  • Phone: 714-230-2430
  • Fax: 714-230-2431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberG79445
License Number StateCA

VIII. Authorized Official

Name: PETER N NEWEN
Title or Position: OWNER
Credential: M.D.
Phone: 714-230-2430