Provider Demographics
NPI:1295362234
Name:MODESTY ELECTROLOGY
Entity Type:Organization
Organization Name:MODESTY ELECTROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MODESTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ISAGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:LE
Authorized Official - Phone:909-954-8363
Mailing Address - Street 1:824 N PASADENA AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2573
Mailing Address - Country:US
Mailing Address - Phone:909-954-8363
Mailing Address - Fax:
Practice Address - Street 1:140 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4259
Practice Address - Country:US
Practice Address - Phone:213-973-3278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty