=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538563507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANCE MEDSPA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2014
-----------------------------------------------------
Last Update Date | 10/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 FIELD POINT RD FIRST FLOOR
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-6441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-717-1414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 FIELD POINT RD FIRST FLOOR
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-6441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-717-1414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOEL B SINGER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 203-717-1414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------