Healthcare Provider Details

I. General information

NPI: 1144036047
Provider Name (Legal Business Name): CELEBRITY MOBILE DNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 VINE ST
HOLLYWOOD CA
90028-5250
US

IV. Provider business mailing address

6936 MORELLA AVE APT 3
NORTH HOLLYWOOD CA
91605-6072
US

V. Phone/Fax

Practice location:
  • Phone: 888-775-4362
  • Fax:
Mailing address:
  • Phone: 213-944-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: SHERISE FORD
Title or Position: FOUNDER
Credential:
Phone: 213-944-4547