MEDICARE: NUFACE LASER & MEDISPA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician

General Provider Information

NPI Number	:	1184679565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUFACE LASER & MEDISPA LLC

Provider Business Mailing Address
First Line	:	117 B GOFF MOUNTAIN RD
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313
Country	:	US
Telephone Number	:	304-204-1310
Fax Number	:	304-204-1311

Provider Business Practice Location Address
First Line	:	117 B GOFF MOUNTAIN RD
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1434
Country	:	US
Telephone Number	:	304-204-1310
Fax Number	:	304-204-1311

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ARVIND VIRADIA
Credential	:	M.D.
Telephone Number	:	304-204-1310

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	10/26/2007

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