Provider Demographics
NPI:1114165875
Name:NEW IMAGE CREATIONS, INC.
Entity Type:Organization
Organization Name:NEW IMAGE CREATIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OPAI-TETTEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-782-8300
Mailing Address - Street 1:4335 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3727
Mailing Address - Country:US
Mailing Address - Phone:818-782-8300
Mailing Address - Fax:818-782-8301
Practice Address - Street 1:14624 SHERMAN WAY
Practice Address - Street 2:SUITE 409
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2241
Practice Address - Country:US
Practice Address - Phone:818-782-8300
Practice Address - Fax:818-782-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53194207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty