Provider Demographics
NPI:1902633126
Name:BUEN VITA IV MED SPA PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BUEN VITA IV MED SPA PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENROSTRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-250-2535
Mailing Address - Street 1:2330 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2013
Mailing Address - Country:US
Mailing Address - Phone:209-250-2535
Mailing Address - Fax:209-633-3433
Practice Address - Street 1:2330 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2013
Practice Address - Country:US
Practice Address - Phone:209-250-2535
Practice Address - Fax:209-633-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty