Provider Demographics
NPI:1649745274
Name:ETERNAL YOUTH MEDICAL SPA
Entity Type:Organization
Organization Name:ETERNAL YOUTH MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:JETT
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-558-9800
Mailing Address - Street 1:902 N. GRAND AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701
Mailing Address - Country:US
Mailing Address - Phone:714-558-9800
Mailing Address - Fax:714-558-9803
Practice Address - Street 1:902 N. GRAND AVENUE
Practice Address - Street 2:SUITE 204
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:714-558-9800
Practice Address - Fax:714-558-9803
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ETERNAL YOUTH MED SPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty