MEDICARE: L'ELITE MEDISPA INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1235719063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L'ELITE MEDISPA INC.

Provider Business Mailing Address
First Line	:	273 WALT WHITMAN RD STE 190
Second Line	:
City	:	HUNTINGTON STATION
State	:	NY
Zip	:	11746-4149
Country	:	US
Telephone Number	:	631-824-6648
Fax Number	:	631-824-9039

Provider Business Practice Location Address
First Line	:	506B WALT WHITMAN RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-2109
Country	:	US
Telephone Number	:	631-824-6648
Fax Number	:	631-824-9039

Authorized Official
Title or Position	:	NURSE PRACTITIONER/OWNER
Name	:	RICHINA LUKES-MILLEDGE
Credential	:	NP
Telephone Number	:	631-455-1965

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	04/14/2021

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