Provider Demographics
NPI:1861627655
Name:SKIN ENVY MED SPA AND WEIGHT LOSS
Entity Type:Organization
Organization Name:SKIN ENVY MED SPA AND WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VASILE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-948-8050
Mailing Address - Street 1:8112 MILLIKEN AVE STE 103-1
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7471
Mailing Address - Country:US
Mailing Address - Phone:909-948-8050
Mailing Address - Fax:909-948-8061
Practice Address - Street 1:8112 MILLIKEN AVE STE 103-1
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7471
Practice Address - Country:US
Practice Address - Phone:909-948-8050
Practice Address - Fax:909-948-8061
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DV URGENT CARE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty