Healthcare Provider Details

I. General information

NPI: 1366629800
Provider Name (Legal Business Name): DERMATOLOGY & COSMETIC CARE, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HAALAND DR. SUITE #204
THOUSAND OAKS CA
91361
US

IV. Provider business mailing address

425 HAALAND DR. SUITE # 204
THOUSAND OAKS CA
91361
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-8080
  • Fax: 805-497-8806
Mailing address:
  • Phone: 805-497-8080
  • Fax: 805-497-8806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA73488
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA73488
License Number StateCA

VIII. Authorized Official

Name: BRIAN RACKOHN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 805-497-8080