Basic Information
| Provider Information | |||||||||
| NPI: | 1679840532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAND DERMATOLOGY AND SKIN CANCER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302410473 | ||||||||
| FaxNumber: | 5302415377 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 W AVENUE Q | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935513892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619479000 | ||||||||
| FaxNumber: | 6612668751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2011 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | HIRSCHFIELD | ||||||||
| AuthorizedOfficialFirstName: | KRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6619479000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.