Provider Demographics
NPI:1104105055
Name:LASPINA RENEWED IMAGE SALON
Entity type:Organization
Organization Name:LASPINA RENEWED IMAGE SALON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LASPINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-628-3439
Mailing Address - Street 1:947 S LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-3254
Mailing Address - Country:US
Mailing Address - Phone:845-628-3439
Mailing Address - Fax:845-628-4838
Practice Address - Street 1:947 S LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-3254
Practice Address - Country:US
Practice Address - Phone:845-628-3439
Practice Address - Fax:845-628-4838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21SU0072981332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21SU0072981OtherOPERARATING AN APPEARANCE ENHANCEMENT BUSINESS LICENSE