Healthcare Provider Details

I. General information

NPI: 1568373777
Provider Name (Legal Business Name): REENVISION AESTHETICS AND MEDSPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 JONES WAY STE 8
SIMI VALLEY CA
93065-1217
US

IV. Provider business mailing address

5746 ZELZAH AVE
ENCINO CA
91316-1155
US

V. Phone/Fax

Practice location:
  • Phone: 818-577-3925
  • Fax:
Mailing address:
  • Phone: 818-577-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN MARTIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 818-577-3925