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General NPI Number Information
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NPI Number | 1811497928
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Entity Type | Organization
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Legal Business Name | LACA DERMATOLOGY, INC
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Dates
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Enumeration Date | 02/15/2018
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Last Update Date | 03/25/2019
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Provider Practice Location Address
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Address Line | 4955 VAN NUYS BLVD STE 516
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City | SHERMAN OAKS
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State | CA
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Zip | 91403-1832
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Country | US
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Telephone | 818-789-6296
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Fax | 818-789-0374
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Provider Business Mailing Address
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Address Line | 1920 HILLHURST AVE #158
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City | LOS ANGELES
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State | CA
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Zip | 90027-3352
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Country | US
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Telephone | 818-789-6296
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Fax | 818-789-0374
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Authorized Official
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Title or Position | MD
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Name | DR. KATHLEEN VINE
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Credential | MD
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Telephone | 818-789-6296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | C53733
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License Number State | CA
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