Provider Demographics
NPI:1134327422
Name:FAMILY HEALTH & MEDICAL AESTHETIC CENTER INC
Entity Type:Organization
Organization Name:FAMILY HEALTH & MEDICAL AESTHETIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEL POZO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:718-496-9203
Mailing Address - Street 1:7607 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6635
Mailing Address - Country:US
Mailing Address - Phone:718-496-9203
Mailing Address - Fax:
Practice Address - Street 1:421 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-7336
Practice Address - Country:US
Practice Address - Phone:718-496-9203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333926363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02744058Medicaid
NY1557G1Medicare ID - Type Unspecified