Healthcare Provider Details

I. General information

NPI: 1437402054
Provider Name (Legal Business Name): PLASTICARE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 EAST WARDLOW ROAD
LONG BEACH CA
90807-4630
US

IV. Provider business mailing address

920 EAST WARDLOW ROAD
LONG BEACH CA
90807-4630
US

V. Phone/Fax

Practice location:
  • Phone: 562-427-8944
  • Fax: 562-427-4086
Mailing address:
  • Phone: 562-427-8944
  • Fax: 562-427-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG25370
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1386(AAAASF)
License Number StateIL

VIII. Authorized Official

Name: IKONIJA SEKULOVICH JOY
Title or Position: DIRECTOR PLASTICARE SURGERY CENTER
Credential: MD
Phone: 562-427-8944