Healthcare Provider Details

I. General information

NPI: 1225227333
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA SKIN AND LASER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22972 MOULTON PKWY STE 106
LAGUNA HILLS CA
92653-1219
US

IV. Provider business mailing address

22972 MOULTON PKWY STE 106
LAGUNA HILLS CA
92653-1219
US

V. Phone/Fax

Practice location:
  • Phone: 949-707-5734
  • Fax: 949-707-1924
Mailing address:
  • Phone: 949-707-5734
  • Fax: 949-707-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA68285
License Number StateCA

VIII. Authorized Official

Name: MS. TANYA Y EVANS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 949-707-5734