Healthcare Provider Details

I. General information

NPI: 1639488588
Provider Name (Legal Business Name): ESTETICA DE ELLA SALON (CRANIAL PROSTHESIS)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 SAN MATEO PL NE
ALBUQUERQUE NM
87110-4064
US

IV. Provider business mailing address

2510 SAN MATEO PL NE
ALBUQUERQUE NM
87110-4064
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-3333
  • Fax: 505-881-2857
Mailing address:
  • Phone: 505-830-3333
  • Fax: 505-881-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberFA0026088
License Number StateNM

VIII. Authorized Official

Name: MR. JAVIER TORRES
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 505-830-3333