1013189075 NPI number — GLO AESTHETIC & LASER INSTITUTE LLC

Table of content: (NPI 1013189075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013189075 NPI number — GLO AESTHETIC & LASER INSTITUTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLO AESTHETIC & LASER INSTITUTE LLC
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:
1013189075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7945 PALACIO DEL MAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33433-4149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-704-4565
Provider Business Mailing Address Fax Number:
561-368-2264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7100 W CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33433-5510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-704-4565
Provider Business Practice Location Address Fax Number:
561-368-2264
Provider Enumeration Date:
03/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DANTON
Authorized Official First Name:
JACK
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
561-704-4565

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS6841 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: OS6841 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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