Healthcare Provider Details

I. General information

NPI: 1093619561
Provider Name (Legal Business Name): BEACON TISSUE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E COLORADO BLVD # 647
PASADENA CA
91105-1938
US

IV. Provider business mailing address

117 E COLORADO BLVD # 647
PASADENA CA
91105-1938
US

V. Phone/Fax

Practice location:
  • Phone: 310-447-5653
  • Fax:
Mailing address:
  • Phone: 310-447-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUZ YANE
Title or Position: CEO
Credential:
Phone: 310-447-5653