Healthcare Provider Details

I. General information

NPI: 1811070964
Provider Name (Legal Business Name): EYESTHESTICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE SUITE 207
PASADENA CA
91105-3150
US

IV. Provider business mailing address

PO BOX 50187
PASADENA CA
91115-0187
US

V. Phone/Fax

Practice location:
  • Phone: 310-360-3922
  • Fax: 310-360-9246
Mailing address:
  • Phone: 310-360-3922
  • Fax: 310-360-9246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAAAHC
License Number StateCA

VIII. Authorized Official

Name: MS. VALERIE KWAN
Title or Position: BILLING MANAGER
Credential:
Phone: 310-360-3922