Healthcare Provider Details

I. General information

NPI: 1467607127
Provider Name (Legal Business Name): TRILLIUM MED SPA COSMETIC SURGERY AND LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2008
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PARK LN STE 200
MOORPARK CA
93021-2117
US

IV. Provider business mailing address

145 PARK LN STE 200
MOORPARK CA
93021-2117
US

V. Phone/Fax

Practice location:
  • Phone: 805-531-9419
  • Fax: 805-531-9494
Mailing address:
  • Phone: 805-531-9419
  • Fax: 805-531-9494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA103922
License Number StateCA

VIII. Authorized Official

Name: TROY CHRISTOPHER WILLIAMS
Title or Position: OWNER
Credential:
Phone: 818-597-9300