=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598030264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M POLLY MCKINSTRY MD PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2012
-----------------------------------------------------
Last Update Date | 03/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23961 CALLE DE LA MAGDALENA STE 402
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-3685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-595-0095
-----------------------------------------------------
Fax | 949-595-4459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23961 CALLE DE LA MAGDALENA STE 402
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-3685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-595-0095
-----------------------------------------------------
Fax | 949-595-4459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRATOR
-----------------------------------------------------
Name | LAVINIA CRUMP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-645-2250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | G54934B
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------