1932029121 NPI number — ADVANDERM CLINICAL MEDSPA, LLC

Table of content: (NPI 1932029121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932029121 NPI number — ADVANDERM CLINICAL MEDSPA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANDERM CLINICAL MEDSPA, 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:
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:
1932029121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1612 SALERNO CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33327-1904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2890 GRIFFIN RD STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33312-5669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-399-9021
Provider Business Practice Location Address Fax Number:
954-708-1435
Provider Enumeration Date:
07/17/2026

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
RAMONA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
954-399-9021

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1740882851 . This is a "NPI1" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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