Provider Demographics
NPI:1922767250
Name:IMMORTELLE INC
Entity Type:Organization
Organization Name:IMMORTELLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-355-9023
Mailing Address - Street 1:468 N CAMDEN DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4507
Mailing Address - Country:US
Mailing Address - Phone:424-355-9023
Mailing Address - Fax:
Practice Address - Street 1:300 S DOHENY DR STE 510
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3704
Practice Address - Country:US
Practice Address - Phone:424-355-9023
Practice Address - Fax:424-389-7037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health