Provider Demographics
NPI:1639876733
Name:PELHAM MEDICAL CONSULTING & AESTHETIC LOUNGE, LLC.
Entity Type:Organization
Organization Name:PELHAM MEDICAL CONSULTING & AESTHETIC LOUNGE, LLC.
Other - Org Name:PELHAM MEDICAL CONSULTING & AESTHETIC LOUNGE, LLC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANADRA
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:GREENIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:407-893-1181
Mailing Address - Street 1:5979 VINELAND RD STE 207
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7855
Mailing Address - Country:US
Mailing Address - Phone:407-893-1181
Mailing Address - Fax:407-440-8269
Practice Address - Street 1:5979 VINELAND RD STE 207
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7855
Practice Address - Country:US
Practice Address - Phone:407-893-1181
Practice Address - Fax:407-440-8269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty