Provider Demographics
NPI:1669629416
Name:SHARP MED SPA INC.
Entity Type:Organization
Organization Name:SHARP MED SPA INC.
Other - Org Name:NEW VOYAGE DRUG AND ALCOHAL REHABILITAION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:SALIMEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRMOTAHARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-619-8850
Mailing Address - Street 1:1150 W CAPITOL DR UNIT 137
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2277
Mailing Address - Country:US
Mailing Address - Phone:310-619-8850
Mailing Address - Fax:
Practice Address - Street 1:6894 S ENSENADA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-1956
Practice Address - Country:US
Practice Address - Phone:303-731-4353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-23
Last Update Date:2008-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1634324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility