Provider Demographics
NPI:1376026815
Name:PERFETTA MEDICAL SPA INC
Entity Type:Organization
Organization Name:PERFETTA MEDICAL SPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:N
Authorized Official - Last Name:SAMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-850-5630
Mailing Address - Street 1:22015 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2942
Mailing Address - Country:US
Mailing Address - Phone:424-264-5859
Mailing Address - Fax:888-444-9401
Practice Address - Street 1:22015 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2942
Practice Address - Country:US
Practice Address - Phone:424-264-5859
Practice Address - Fax:888-444-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA083078AOtherBUSINESS LICENSE