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General NPI Number Information
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NPI Number | 1578078127
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Entity Type | Organization
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Legal Business Name | LICE CLINICS OF AMERICA LAX
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Dates
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Enumeration Date | 12/05/2017
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Last Update Date | 12/05/2017
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Provider Practice Location Address
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Address Line | 5587 W MANCHESTER AVE
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City | LOS ANGELES
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State | CA
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Zip | 90045-4413
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Country | US
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Telephone | 310-999-5343
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Fax |
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Provider Business Mailing Address
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Address Line | 11912 BRAY ST
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City | CULVER CITY
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State | CA
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Zip | 90230
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Country | US
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Telephone | 310-999-5343
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Fax |
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Authorized Official
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Title or Position | OWNER/TECH
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Name | MR. MARIO DANNY ESQUIVEL SR.
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Credential |
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Telephone | 310-999-5343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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