Provider Demographics
NPI:1346992047
Name:LYMPHATIC AESTHETICS L. A. WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:LYMPHATIC AESTHETICS L. A. WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEANDREA
Authorized Official - Middle Name:TONIKA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:386-316-4713
Mailing Address - Street 1:3376 MCCORMICK WOODS DR.
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4443
Mailing Address - Country:US
Mailing Address - Phone:305-791-4262
Mailing Address - Fax:305-402-6471
Practice Address - Street 1:3376 MCCORMICK WOODS DR.
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4443
Practice Address - Country:US
Practice Address - Phone:305-791-4262
Practice Address - Fax:305-402-6471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service