Healthcare Provider Details

I. General information

NPI: 1841058757
Provider Name (Legal Business Name): ILONA V MALYGIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILONA MALYGIN LUNA SKIN SOLUTION

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16550 VENTURA BLVD STE 204
ENCINO CA
91436-4563
US

IV. Provider business mailing address

13439 MOORPARK ST # 39E
SHERMAN OAKS CA
91423-3841
US

V. Phone/Fax

Practice location:
  • Phone: 818-300-7930
  • Fax:
Mailing address:
  • Phone: 818-300-7930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberPR0282219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: