Provider Demographics
NPI:1578078127
Name:LICE CLINICS OF AMERICA LAX
Entity Type:Organization
Organization Name:LICE CLINICS OF AMERICA LAX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/TECH
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:DANNY
Authorized Official - Last Name:ESQUIVEL
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:310-999-5343
Mailing Address - Street 1:11912 BRAY ST
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230
Mailing Address - Country:US
Mailing Address - Phone:310-999-5343
Mailing Address - Fax:
Practice Address - Street 1:5587 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4413
Practice Address - Country:US
Practice Address - Phone:310-999-5343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center