=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942759154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANESSA GABROVSKY CUELLAR MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2016
-----------------------------------------------------
Last Update Date | 09/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 N ROXBURY DR 3RD FLOOR
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-385-7766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 N ROXBURY DR 3RD FLOOR
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-385-7766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. VANESSA GABROVSKY CUELLAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-744-7591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | A134536
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------