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General NPI Number Information
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NPI Number | 1568561256
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Entity Type | Organization
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Legal Business Name | CITY OF ANGELS DERMATOLOGY, INC.
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 10/15/2008
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Provider Practice Location Address
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Address Line | 8631 W 3RD ST SUITE 1135 E
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City | LOS ANGELES
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State | CA
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Zip | 90048-5901
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Country | US
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Telephone | 310-651-8240
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Fax | 310-651-8254
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Provider Business Mailing Address
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Address Line | 4712 ADMIRALTY WAY SUITE 665
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6905
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Country | US
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Telephone | 310-651-8240
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Fax | 310-651-8254
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MR. MARTIN GLENN BILLIPS
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Credential |
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Telephone | 310-261-4963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | CA
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