Healthcare Provider Details

I. General information

NPI: 1184651457
Provider Name (Legal Business Name): MARIN COSMETIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ROWLAND WAY # 302
NOVATO CA
94945-5038
US

IV. Provider business mailing address

11999 SAN VICENTE BLVD # 440
LOS ANGELES CA
90049-5131
US

V. Phone/Fax

Practice location:
  • Phone: 415-898-4361
  • Fax: 415-897-4664
Mailing address:
  • Phone: 310-440-3131
  • Fax: 310-471-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MIGUEL A. DELGADO II
Title or Position: OWNER
Credential: M.D.
Phone: 415-898-4161