Healthcare Provider Details

I. General information

NPI: 1346992047
Provider Name (Legal Business Name): LYMPHATIC AESTHETICS L. A. WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 02/12/2022
Certification Date: 02/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3376 MCCORMICK WOODS DR.
OCOEE FL
34761-4443
US

IV. Provider business mailing address

3376 MCCORMICK WOODS DR.
OCOEE FL
34761-4443
US

V. Phone/Fax

Practice location:
  • Phone: 305-791-4262
  • Fax: 305-402-6471
Mailing address:
  • Phone: 305-791-4262
  • Fax: 305-402-6471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEANDREA TONIKA LONG
Title or Position: OWNER
Credential: APRN
Phone: 386-316-4713