Healthcare Provider Details

I. General information

NPI: 1073346789
Provider Name (Legal Business Name): BODYBY ULTIMATE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2777 PACIFIC AVE SUITE I
LONG BEACH CA
90806
US

IV. Provider business mailing address

2777 PACIFIC AVE SUITE I
LONG BEACH CA
90806
US

V. Phone/Fax

Practice location:
  • Phone: 562-336-1511
  • Fax: 562-336-1510
Mailing address:
  • Phone: 562-336-1511
  • Fax: 562-336-1510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. HYDER MUKADAM SR.
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 562-336-1511