Provider Demographics
NPI:1740607845
Name:AGAPE MEDICAL SPA AND WEIGHT LOSS CENTER LLC
Entity Type:Organization
Organization Name:AGAPE MEDICAL SPA AND WEIGHT LOSS CENTER LLC
Other - Org Name:AGAPE DERMATOLOGY OF FALL RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENDITALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-294-5988
Mailing Address - Street 1:775 DAVOL ST STE 300
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-1005
Mailing Address - Country:US
Mailing Address - Phone:774-488-5888
Mailing Address - Fax:508-674-8880
Practice Address - Street 1:775 DAVOL ST STE 300
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-1005
Practice Address - Country:US
Practice Address - Phone:774-488-5888
Practice Address - Fax:508-674-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA079000499Medicare UPIN