Provider Demographics
NPI:1912231895
Name:MEDICAL SPA MOKSHA, L.L.C.
Entity Type:Organization
Organization Name:MEDICAL SPA MOKSHA, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-980-9393
Mailing Address - Street 1:500 CAHABA PARK CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5087
Mailing Address - Country:US
Mailing Address - Phone:205-980-9393
Mailing Address - Fax:205-980-4494
Practice Address - Street 1:500 CAHABA PARK CIR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-5087
Practice Address - Country:US
Practice Address - Phone:205-980-9393
Practice Address - Fax:205-980-4494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3370208200000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306901517OtherNPI
ALC75686Medicare UPIN