Healthcare Provider Details

I. General information

NPI: 1164021598
Provider Name (Legal Business Name): J S VINCENT MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 10/18/2020
Certification Date: 10/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 LOS FELIZ BLVD STE 103
LOS ANGELES CA
90039-1599
US

IV. Provider business mailing address

3111 LOS FELIZ BLVD STE 103
LOS ANGELES CA
90039-1599
US

V. Phone/Fax

Practice location:
  • Phone: 770-895-8483
  • Fax:
Mailing address:
  • Phone: 770-895-8483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN BUTORA
Title or Position: BILLING MANAGER
Credential:
Phone: 562-787-0225