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General NPI Number Information
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NPI Number | 1043249972
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Entity Type | Organization
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Legal Business Name | PLASTIC AND RECONSTRUCTIVE SURGERY
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Dates
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Enumeration Date | 07/02/2006
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Last Update Date | 05/09/2012
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Provider Practice Location Address
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Address Line | 1387 SANTA RITA RD
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City | PLEASANTON
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State | CA
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Zip | 94566-5643
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Country | US
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Telephone | 925-462-3700
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Fax | 925-462-4681
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Provider Business Mailing Address
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Address Line | 1387 SANTA RITA RD
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City | PLEASANTON
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State | CA
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Zip | 94566-5643
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Country | US
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Telephone | 925-462-3700
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Fax | 925-462-4681
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. JUDI HICKLIN
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Credential |
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Telephone | 925-462-3700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 140000491
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License Number State | CA
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