Healthcare Provider Details

I. General information

NPI: 1659744175
Provider Name (Legal Business Name): UCR HEALTH- PLASTIC & RECONSTRUCTIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10694 MAGNOLIA AVE
RIVERSIDE CA
92505-1816
US

IV. Provider business mailing address

PO BOX 31001-2130
PASADENA CA
91110-2130
US

V. Phone/Fax

Practice location:
  • Phone: 951-827-7587
  • Fax: 951-402-2802
Mailing address:
  • Phone: 213-412-1973
  • Fax: 213-412-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JOHN HEYDT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 714-456-2986