Healthcare Provider Details

I. General information

NPI: 1588966238
Provider Name (Legal Business Name): LA JOLLA COSMETIC LASER CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7720 FAY AVE
LA JOLLA CA
92037-4309
US

IV. Provider business mailing address

7720 FAY AVE
LA JOLLA CA
92037-4309
US

V. Phone/Fax

Practice location:
  • Phone: 858-454-2700
  • Fax: 858-454-2782
Mailing address:
  • Phone: 858-454-2700
  • Fax: 858-454-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAULA ORTIZ
Title or Position: MEDICAL BILLING COORDINATOR
Credential:
Phone: 858-454-2700