Provider Demographics
NPI:1598236358
Name:AVALON SKIN CARE AND ELECTROLYSIS INC
Entity Type:Organization
Organization Name:AVALON SKIN CARE AND ELECTROLYSIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GEMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:ELECTROLYSIST
Authorized Official - Phone:650-344-5555
Mailing Address - Street 1:430 PENINSULA AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-1683
Mailing Address - Country:US
Mailing Address - Phone:650-344-5555
Mailing Address - Fax:
Practice Address - Street 1:430 PENINSULA AVE STE 8
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1683
Practice Address - Country:US
Practice Address - Phone:650-344-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVALON SKIN CARE AND ELECTROLYSIS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-05
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty