Provider Demographics
NPI:1265006258
Name:111 FASHION LANE LLC
Entity Type:Organization
Organization Name:111 FASHION LANE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:YEN
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-429-9290
Mailing Address - Street 1:111 FASHION LN
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3306
Mailing Address - Country:US
Mailing Address - Phone:714-619-8636
Mailing Address - Fax:866-646-1488
Practice Address - Street 1:111 FASHION LN
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3306
Practice Address - Country:US
Practice Address - Phone:714-619-8636
Practice Address - Fax:866-646-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care