=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316292741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAUTIFUL SKIN ESSENTIALS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2012
-----------------------------------------------------
Last Update Date | 10/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16420 PERRIS BLVD SUITE #L
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92551-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-703-3767
-----------------------------------------------------
Fax | 310-539-5722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 CRENSHAW BLVD SUITE 224
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90501-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-539-5980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ERNEST Z MOZIA
-----------------------------------------------------
Credential | LVN,BS-BUSI. MGT.
-----------------------------------------------------
Telephone | 800-539-5980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WR0006X
-----------------------------------------------------
Taxonomy Name | Registered Nurse First Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11282
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------