Healthcare Provider Details

I. General information

NPI: 1063848828
Provider Name (Legal Business Name): XANIA DARDEN COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NECIE DARDEN COSMETOLOGIST

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23331 EL TORO RD SUITE 114
LAKE FOREST CA
92630-4891
US

IV. Provider business mailing address

4 AVENTINE
ALISO VIEJO CA
92656-4296
US

V. Phone/Fax

Practice location:
  • Phone: 949-215-0994
  • Fax:
Mailing address:
  • Phone: 949-215-0994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberB87443
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberB87443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: