Healthcare Provider Details

I. General information

NPI: 1306976808
Provider Name (Legal Business Name): FACIAL RECONSTRUCTIVE SURGICAL AND MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WELCH RD. SUITE 317
PALO ALTO CA
94304-1510
US

IV. Provider business mailing address

750 WELCH RD. SUITE 317
PALO ALTO CA
94304-1510
US

V. Phone/Fax

Practice location:
  • Phone: 650-328-0511
  • Fax: 650-328-3419
Mailing address:
  • Phone: 650-328-0511
  • Fax: 650-328-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROLYN S. ODERIO
Title or Position: OFFICE MANAGER
Credential:
Phone: 650-328-0511