Provider Demographics
NPI:1568808731
Name:MED THERAPEUTIC SKIN CARE DAY SPA
Entity Type:Organization
Organization Name:MED THERAPEUTIC SKIN CARE DAY SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSQUERA
Authorized Official - Suffix:
Authorized Official - Credentials:LPG
Authorized Official - Phone:770-849-0206
Mailing Address - Street 1:5344 JIMMY CARTER BLVD
Mailing Address - Street 2:1 C
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1516
Mailing Address - Country:US
Mailing Address - Phone:770-849-0206
Mailing Address - Fax:770-849-0206
Practice Address - Street 1:5344 JIMMY CARTER BLVD
Practice Address - Street 2:1 C
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1516
Practice Address - Country:US
Practice Address - Phone:770-849-0206
Practice Address - Fax:770-849-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2013005065261QM0850X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health