Healthcare Provider Details

I. General information

NPI: 1922962604
Provider Name (Legal Business Name): MEDICAL SPA MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 LIBERTY RD STE 100
ELDERSBURG MD
21784-7941
US

IV. Provider business mailing address

1030 LIBERTY RD STE 100
ELDERSBURG MD
21784-7941
US

V. Phone/Fax

Practice location:
  • Phone: 443-398-8425
  • Fax:
Mailing address:
  • Phone: 443-398-8425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: EMMA SORENSON
Title or Position: OWNER
Credential: PA-C
Phone: 443-398-8425