=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780342394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL AESTHETICS AND MEDICAL CENTRE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2021
-----------------------------------------------------
Last Update Date | 12/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1403 LOMITA BLVD STE 307
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-2085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-352-0326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1403 LOMITA BLVD STE 307
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-2085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-352-0326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT /CEO
-----------------------------------------------------
Name | RICHARD C KEECH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 424-352-0326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------