Provider Demographics
NPI:1821321209
Name:FOUNTAIN OF YOUTH COSMETIC CENTER
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH COSMETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-653-0180
Mailing Address - Street 1:17100 NORWALK BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2750
Mailing Address - Country:US
Mailing Address - Phone:562-653-0180
Mailing Address - Fax:562-402-3029
Practice Address - Street 1:17100 NORWALK BLVD STE 111
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2750
Practice Address - Country:US
Practice Address - Phone:562-653-0180
Practice Address - Fax:562-402-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty