Provider Demographics
NPI:1043601271
Name:ANEW MEDSPA 2120 LLC
Entity Type:Organization
Organization Name:ANEW MEDSPA 2120 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALCMACHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-255-5201
Mailing Address - Street 1:2120 S GREEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3349
Mailing Address - Country:US
Mailing Address - Phone:216-255-5201
Mailing Address - Fax:
Practice Address - Street 1:2120 S GREEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3349
Practice Address - Country:US
Practice Address - Phone:216-255-5201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.016769261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental