Healthcare Provider Details

I. General information

NPI: 1750290730
Provider Name (Legal Business Name): VITALSKIN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 LAUREL CANYON BLVD STE 116
VALLEY VILLAGE CA
91607-2763
US

IV. Provider business mailing address

5301 LAUREL CANYON BLVD STE 116
VALLEY VILLAGE CA
91607-2763
US

V. Phone/Fax

Practice location:
  • Phone: 949-628-4115
  • Fax:
Mailing address:
  • Phone: 949-628-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NATTAPONG LERTWANARIN
Title or Position: CEO
Credential:
Phone: 949-628-4115