1578078127 NPI number — LICE CLINICS OF AMERICA LAX

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578078127 NPI number — LICE CLINICS OF AMERICA LAX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LICE CLINICS OF AMERICA LAX
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:
1578078127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11912 BRAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-999-5343
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5587 W MANCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90045-4413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-999-5343
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESQUIVEL
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
DANNY
Authorized Official Title or Position:
OWNER/TECH
Authorized Official Telephone Number:
310-999-5343

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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