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General NPI Number Information
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NPI Number | 1053506287
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Entity Type | Organization
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Legal Business Name | LA QUINTA MEDSPA, INC.
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 02/22/2010
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Provider Practice Location Address
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Address Line | 47-350 WASHINGTON STREET SUITE 103
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City | LA QUINTA
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State | CA
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Zip | 92253
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Country | US
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Telephone | 760-396-9353
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Fax | 760-564-9577
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Provider Business Mailing Address
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Address Line | 47350 WASHINGTON ST SUITE 103
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City | LA QUINTA
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State | CA
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Zip | 92253-8847
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Country | US
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Telephone | 760-396-9353
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Fax | 760-564-9577
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MATTHEW LOREN WERNER
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Credential | M.D.
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Telephone | 760-396-9353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G79952
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License Number State | CA
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