Provider Demographics
NPI:1699825281
Name:FACIALSPA INC.
Entity Type:Organization
Organization Name:FACIALSPA INC.
Other - Org Name:PROJECT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENLAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:760-722-3939
Mailing Address - Street 1:314 WISCONSIN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-4157
Mailing Address - Country:US
Mailing Address - Phone:760-722-3939
Mailing Address - Fax:760-722-0718
Practice Address - Street 1:314 WISCONSIN AVE STE C
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-4157
Practice Address - Country:US
Practice Address - Phone:760-722-3939
Practice Address - Fax:760-722-0718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100858332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME00776FMedicaid
CADME00776FMedicaid