Provider Demographics
NPI:1952526873
Name:BIOVISAGE ACUPUNCTURE FACELIFT CLINIC
Entity Type:Organization
Organization Name:BIOVISAGE ACUPUNCTURE FACELIFT CLINIC
Other - Org Name:BIOVISAGE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NILOUFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MSOM
Authorized Official - Phone:323-655-8220
Mailing Address - Street 1:3660 AMESBURY RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1304
Mailing Address - Country:US
Mailing Address - Phone:323-655-8220
Mailing Address - Fax:
Practice Address - Street 1:9105 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3106
Practice Address - Country:US
Practice Address - Phone:323-655-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6481171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty