Healthcare Provider Details

I. General information

NPI: 1629002167
Provider Name (Legal Business Name): UPLAND DERMATOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 N ALTA #103
UPLAND CA
91786
US

IV. Provider business mailing address

P.O. BOX 15807
BEVERLY HILL CA
90209
US

V. Phone/Fax

Practice location:
  • Phone: 909-932-0014
  • Fax:
Mailing address:
  • Phone: 909-860-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JOY FORTICH
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 909-860-7600