Provider Demographics
NPI:1245000249
Name:FLAWLESS SKIN IV HYDRATION MED SPA
Entity type:Organization
Organization Name:FLAWLESS SKIN IV HYDRATION MED SPA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,MSN,CNL,RN
Authorized Official - Phone:323-538-1110
Mailing Address - Street 1:25101 THE OLD RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-2206
Mailing Address - Country:US
Mailing Address - Phone:323-538-1110
Mailing Address - Fax:
Practice Address - Street 1:25101 THE OLD RD
Practice Address - Street 2:
Practice Address - City:STEVENSON RANCH
Practice Address - State:CA
Practice Address - Zip Code:91381-2206
Practice Address - Country:US
Practice Address - Phone:323-538-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center