Provider Demographics
NPI:1568687853
Name:EYESTHETICA
Entity type:Organization
Organization Name:EYESTHETICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-234-1011
Mailing Address - Street 1:500 MOLINO ST STE 107
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-2271
Mailing Address - Country:US
Mailing Address - Phone:213-234-1000
Mailing Address - Fax:213-234-1001
Practice Address - Street 1:625 S FAIR OAKS AVE STE 265
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:213-234-1000
Practice Address - Fax:213-234-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091240Medicaid
CAZZZ06818ZOtherMEDICARE PIN; PALM SPRING
CAGR0091240Medicaid
CAZZZ06818ZOtherMEDICARE PIN; PALM SPRING
CAW21549Medicare PIN
CA=========OtherEYESTHETICA TAX ID
CAA45940Medicare UPIN
CAGR0091240Medicaid