=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821321209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNTAIN OF YOUTH COSMETIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2009
-----------------------------------------------------
Last Update Date | 09/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17100 NORWALK BLVD STE 111
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-653-0180
-----------------------------------------------------
Fax | 562-402-3029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17100 NORWALK BLVD STE 111
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-653-0180
-----------------------------------------------------
Fax | 562-402-3029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANIL K GANDHI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 562-653-0180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A30411
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------