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NPI Code Detail

MEDICARE: LUMINOUS SKIN DERMATOLOGY AND COSMETIC INSTITUTE INC

MEDICARE: LUMINOUS SKIN DERMATOLOGY AND COSMETIC INSTITUTE 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
1261QM2500XMedical Specialty Clinic/CenterFNP40648CA

General Provider Information

NPI Number : 1982904892
Entity Type Code : Organization
Provider Name (Legal Business Name) : LUMINOUS SKIN DERMATOLOGY AND COSMETIC INSTITUTE INC
Provider Business Mailing Address
First Line : 119 W TORRANCE BLVD
Second Line : SUITE 7
City : REDONDO BEACH
State : CA
Zip : 90277-3600
Country : US
Telephone Number : 310-374-3100
Fax Number : 310-374-3155
Provider Business Practice Location Address
First Line : 119 W TORRANCE BLVD
Second Line : SUITE 7
City : REDONDO BEACH
State : CA
Zip : 90277-3600
Country : US
Telephone Number : 310-374-3100
Fax Number : 310-374-3155
Authorized Official
Title or Position : PRESIDENT
Name : ALEXANDRIA V BOOTH
Credential : MD
Telephone Number : 310-374-3100
Provider Enumeration Date : 10/26/2010
Last Update Date : 10/26/2010

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Directions to “LUMINOUS SKIN DERMATOLOGY AND COSMETIC INSTITUTE INC ” Practice Location

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