Healthcare Provider Details

I. General information

NPI: 1730258187
Provider Name (Legal Business Name): RENAISSANCE ASTHETIC LASER AND VEIN INSTITUTE, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 ROLLING OAKS DR STE 202
THOUSAND OAKS CA
91361-1018
US

IV. Provider business mailing address

77 ROLLING OAKS DR STE 202
THOUSAND OAKS CA
91361-1018
US

V. Phone/Fax

Practice location:
  • Phone: 805-379-6717
  • Fax:
Mailing address:
  • Phone: 805-379-6717
  • Fax: 805-379-6719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GHOLAM REZA MOHAMMADZADEH
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 805-379-6717