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General NPI Number Information
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NPI Number | 1295188944
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Entity Type | Organization
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Legal Business Name | LA TANS, SPA & MEDICAL AESTHETICS INC
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Dates
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Enumeration Date | 07/18/2016
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Last Update Date | 07/18/2016
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Provider Practice Location Address
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Address Line | 1811 NE 123RD ST
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City | NORTH MIAMI
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State | FL
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Zip | 33181-2805
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Country | US
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Telephone | 305-987-0511
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Fax |
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Provider Business Mailing Address
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Address Line | 1811 NE 123RD ST
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City | NORTH MIAMI
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State | FL
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Zip | 33181-2805
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Country | US
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Telephone | 305-987-0511
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Fax |
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Authorized Official
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Title or Position | BILLING OFFICER
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Name | XAVIER MARTINEZ
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Credential | CPC
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Telephone | 305-987-0511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME81585
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License Number State | FL
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