Provider Demographics
NPI:1033733779
Name:SOUTH BAY REGENERATIVE MEDICAL SPA INC
Entity Type:Organization
Organization Name:SOUTH BAY REGENERATIVE MEDICAL SPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-474-9053
Mailing Address - Street 1:412 S PACIFIC COAST HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3712
Mailing Address - Country:US
Mailing Address - Phone:310-792-9100
Mailing Address - Fax:310-792-1180
Practice Address - Street 1:412 S PACIFIC COAST HWY STE 100
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3712
Practice Address - Country:US
Practice Address - Phone:310-792-9100
Practice Address - Fax:310-792-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty