Provider Demographics
NPI:1427897735
Name:AESTHETEMED, LLC
Entity type:Organization
Organization Name:AESTHETEMED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NISENBOYM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-966-7878
Mailing Address - Street 1:2100 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:100
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009
Mailing Address - Country:US
Mailing Address - Phone:786-966-7878
Mailing Address - Fax:
Practice Address - Street 1:2100 E HALLANDALE BEACH BLVD
Practice Address - Street 2:100
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009
Practice Address - Country:US
Practice Address - Phone:786-966-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6025783OtherDEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
FLCE10037989OtherDEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION