Healthcare Provider Details

I. General information

NPI: 1700458973
Provider Name (Legal Business Name): THE INSTITUTE FOR ADVANCED BREAST RECONSTRUCTION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 ROLLING OAKS DR STE 220
THOUSAND OAKS CA
91361-1046
US

IV. Provider business mailing address

5887 ANNIE OAKLEY RD
HIDDEN HILLS CA
91302-1200
US

V. Phone/Fax

Practice location:
  • Phone: 818-336-1295
  • Fax:
Mailing address:
  • Phone: 818-671-7956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DHIVYA SRINIVASA
Title or Position: CEO
Credential: MD
Phone: 818-671-7956