Healthcare Provider Details

I. General information

NPI: 1114384518
Provider Name (Legal Business Name): ILLUMINATE PLASTIC SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 EL CAMINO REAL STE C
PALO ALTO CA
94306-1000
US

IV. Provider business mailing address

1515 EL CAMINO REAL STE C
PALO ALTO CA
94306-1000
US

V. Phone/Fax

Practice location:
  • Phone: 650-433-8621
  • Fax: 650-322-8481
Mailing address:
  • Phone: 650-433-8621
  • Fax: 650-322-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA98186
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID J BOUDREAULT
Title or Position: OWNER
Credential: M.D.
Phone: 650-433-8621