=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003824434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHRIDGE FACIAL PLASTIC SURGERY MEDICAL GROUP A PROFESSIONAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2006
-----------------------------------------------------
Last Update Date | 10/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18350 ROSCOE BLVD #318A
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-993-9824
-----------------------------------------------------
Fax | 818-993-0937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18350 ROSCOE BLVD # 318A
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-993-9824
-----------------------------------------------------
Fax | 818-993-0937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. MARC M KERNER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-349-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | S051366
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------