Provider Demographics
NPI:1508992199
Name:AESTHETIC LASER & VEIN CENTER OF THE NORTH BAY
Entity Type:Organization
Organization Name:AESTHETIC LASER & VEIN CENTER OF THE NORTH BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-542-8346
Mailing Address - Street 1:170 FARMERS LN STE 6B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 FARMERS LN STE 6B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4768
Practice Address - Country:US
Practice Address - Phone:707-542-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA657374174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01461ZMedicare ID - Type UnspecifiedPNI