1497329940 NPI number — BAY AREA ESTHETICS PLASTIC SURGERY INC

Table of content: (NPI 1497329940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497329940 NPI number — BAY AREA ESTHETICS PLASTIC SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY AREA ESTHETICS PLASTIC SURGERY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497329940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 DIVISADERO ST. PMB 759
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94117-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-523-5235
Provider Business Mailing Address Fax Number:
415-523-5235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 SONOMA AVE STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95405-4833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-339-8921
Provider Business Practice Location Address Fax Number:
415-523-5235
Provider Enumeration Date:
05/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
POURTAHERI
Authorized Official First Name:
NAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND SECRETARY
Authorized Official Telephone Number:
415-523-5235

Provider Taxonomy Codes

  • Taxonomy code: 163WW0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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