Healthcare Provider Details

I. General information

NPI: 1912506601
Provider Name (Legal Business Name): KINTSUGI SURGICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD STE 1000
LOS ANGELES CA
90017-4001
US

IV. Provider business mailing address

1127 WILSHIRE BLVD STE 1000
LOS ANGELES CA
90017-4001
US

V. Phone/Fax

Practice location:
  • Phone: 213-328-3600
  • Fax: 213-395-0683
Mailing address:
  • Phone: 213-328-3600
  • Fax: 213-395-0683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEREK TAN DEE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 213-328-3600