=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427602689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA BEAUTE AESTHETICS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 07/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4433 W 29TH AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80212-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-715-6440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4433 W 29TH AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80212-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-715-6440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | MS. MARINA VLADIMIROVNA BACHURINA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-715-6440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------