=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932823671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASESU LASER MED SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2022
-----------------------------------------------------
Last Update Date | 09/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4940 VAN NUYS BLVD STE 306
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-495-8883
-----------------------------------------------------
Fax | 214-271-9831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4940 VAN NUYS BLVD STE 306
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-495-8883
-----------------------------------------------------
Fax | 214-271-9831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. CARIDAD AGUILA-VIVAR
-----------------------------------------------------
Credential | RD
-----------------------------------------------------
Telephone | 661-495-8883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------