MEDICARE: CAPISTRANO SKIN CANCER CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center		CA

General Provider Information

NPI Number	:	1659739837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPISTRANO SKIN CANCER CENTER, INC

Provider Business Mailing Address
First Line	:	30280 RANCHO VIEJO RD
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1561
Country	:	US
Telephone Number	:	949-248-1632
Fax Number	:

Provider Business Practice Location Address
First Line	:	30280 RANCHO VIEJO RD
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1561
Country	:	US
Telephone Number	:	949-248-1632
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DAWN MARIE LEIVA
Credential	:
Telephone Number	:	949-248-1632

Provider Enumeration Date	:	02/03/2016
Last Update Date	:	07/21/2022

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