1366912446 NPI number — VASCULAR COSMETICS LA

Table of content: (NPI 1366912446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366912446 NPI number — VASCULAR COSMETICS LA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VASCULAR COSMETICS LA
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:
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:
1366912446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 HEATHER HILL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92653-6043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-641-1344
Provider Business Mailing Address Fax Number:
818-484-8243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1511 W GLENOAKS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91201-1912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-482-0016
Provider Business Practice Location Address Fax Number:
818-484-8243
Provider Enumeration Date:
11/30/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KHODAVERDIAN
Authorized Official First Name:
REZA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-482-0016

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A127413 . This is a "MED LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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