Provider Demographics
NPI:1104282714
Name:SANCTUARY MEDICAL AESTHETIC CENTER OF BOCA RATON LLC
Entity type:Organization
Organization Name:SANCTUARY MEDICAL AESTHETIC CENTER OF BOCA RATON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-430-6644
Mailing Address - Street 1:4800 N FEDERAL HWY
Mailing Address - Street 2:SUITE C100
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-5188
Mailing Address - Country:US
Mailing Address - Phone:561-886-0970
Mailing Address - Fax:
Practice Address - Street 1:4800 N FEDERAL HWY
Practice Address - Street 2:SUITE C100
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-5188
Practice Address - Country:US
Practice Address - Phone:561-886-0970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty