Provider Demographics
NPI:1902393168
Name:DEJA VU MEDSPA
Entity Type:Organization
Organization Name:DEJA VU MEDSPA
Other - Org Name:DEJA VU MED SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER6266960049
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BEAUCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-696-0049
Mailing Address - Street 1:38 E HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3253
Mailing Address - Country:US
Mailing Address - Phone:626-696-0049
Mailing Address - Fax:
Practice Address - Street 1:38 E HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3253
Practice Address - Country:US
Practice Address - Phone:626-696-0049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17614261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care