Provider Demographics
NPI:1447077177
Name:PACIFIC SHORES DERMATOLOGY & SKIN CANCER INSTITUTE
Entity type:Organization
Organization Name:PACIFIC SHORES DERMATOLOGY & SKIN CANCER INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-217-1457
Mailing Address - Street 1:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-2505
Mailing Address - Country:US
Mailing Address - Phone:805-202-8245
Mailing Address - Fax:805-202-8117
Practice Address - Street 1:860 OAK PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1800
Practice Address - Country:US
Practice Address - Phone:805-202-8245
Practice Address - Fax:805-202-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty