Healthcare Provider Details

I. General information

NPI: 1609052893
Provider Name (Legal Business Name): CALIFORNIA INSTITUTE OF PLASTIC AND RECONSTRUCTIVE SURGERY A MED. CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 EL CAMINO REAL STE 150
SAN DIEGO CA
92130-3037
US

IV. Provider business mailing address

11515 EL CAMINO REAL STE 150
SAN DIEGO CA
92130-3037
US

V. Phone/Fax

Practice location:
  • Phone: 858-720-1440
  • Fax: 858-509-7738
Mailing address:
  • Phone: 858-720-1440
  • Fax: 858-509-7738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberG63907
License Number StateCA

VIII. Authorized Official

Name: GILBERT WESLEY LEE
Title or Position: PHYSICIAN / OWNER
Credential: M.D.
Phone: 858-720-1440