1740695139 NPI number — HOLLYWOOD LIFESTYLE DERMAOTOGY

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 1740695139 NPI number — HOLLYWOOD LIFESTYLE DERMAOTOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLYWOOD LIFESTYLE DERMAOTOGY
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:
1740695139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7135 HOLLYWOOD BLVD
Provider Second Line Business Mailing Address:
#306
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90046-3212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-301-3378
Provider Business Mailing Address Fax Number:
213-256-0685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7135 HOLLYWOOD BLVD
Provider Second Line Business Practice Location Address:
#306
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90046-3212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-301-3378
Provider Business Practice Location Address Fax Number:
213-256-0685
Provider Enumeration Date:
06/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SABAT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
323-600-4156

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  20A 8743 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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