Organization
PLASTIC AND RECONSTRUCTIVE SURGERY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JUDI HICKLIN (ADMINISTRATOR)
(925) 462-3700
Entity
Organization
Contact information
Practice address
1387 SANTA RITA RD, PLEASANTON, CA 94566-5643
(925) 462-3700
(925) 462-4681
Mailing address
1387 SANTA RITA RD, PLEASANTON, CA 94566-5643
(925) 462-3700
(925) 462-4681
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
140000491
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
051102
BLUE CROSS
CA
Enumeration date
07/02/2006
Last updated
05/09/2012
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