Healthcare Provider Details

I. General information

NPI: 1902099765
Provider Name (Legal Business Name): EAST BAY ENT FAC PLAS SG MD GRP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 NORRIS CANYON RD SUITE 302
SAN RAMON CA
94583-5409
US

IV. Provider business mailing address

5401 NORRIS CANYON RD SUITE 302
SAN RAMON CA
94583-5409
US

V. Phone/Fax

Practice location:
  • Phone: 925-277-9000
  • Fax:
Mailing address:
  • Phone: 925-277-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberC031854
License Number StateCA

VIII. Authorized Official

Name: STEPHEN LARMORE
Title or Position: OWNER
Credential: M.D.
Phone: 925-277-9000