Provider Demographics
NPI:1033529946
Name:GRANDE DUNES OBGYN AND FACIAL AESTHETICS PA
Entity Type:Organization
Organization Name:GRANDE DUNES OBGYN AND FACIAL AESTHETICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:LEYEN
Authorized Official - Last Name:VU-MOLASCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-839-2229
Mailing Address - Street 1:913 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4116
Mailing Address - Country:US
Mailing Address - Phone:843-839-2229
Mailing Address - Fax:843-839-2230
Practice Address - Street 1:913 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4116
Practice Address - Country:US
Practice Address - Phone:843-839-2229
Practice Address - Fax:843-839-2230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC278586Medicaid