Provider Demographics
NPI:1992545230
Name:PROSPERA INTERNAL MEDICINE & AESTHETICS, INC.
Entity type:Organization
Organization Name:PROSPERA INTERNAL MEDICINE & AESTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LEA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:619-518-1061
Mailing Address - Street 1:4452 PARK BLVD STE 306
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4049
Mailing Address - Country:US
Mailing Address - Phone:619-206-4232
Mailing Address - Fax:833-972-5097
Practice Address - Street 1:4452 PARK BLVD STE 306
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4049
Practice Address - Country:US
Practice Address - Phone:619-206-4232
Practice Address - Fax:833-972-5097
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?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service