=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609244417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUSTIN B. HELLER,M.D., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2015
-----------------------------------------------------
Last Update Date | 09/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23838 VALENCIA BLVD SUITE 260
-----------------------------------------------------
City | VALENCIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91355-5319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-233-4949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15911 WARM SPRINGS DR
-----------------------------------------------------
City | CANYON COUNTRY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91387-4043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-233-4949
-----------------------------------------------------
Fax | 661-705-5101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUSTIN BOYD HELLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 817-209-5309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | A111496
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------