Provider Demographics
NPI:1144546789
Name:ANTI AGING AESTHETIC AND LASER CENTER INC
Entity type:Organization
Organization Name:ANTI AGING AESTHETIC AND LASER CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:RYBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-539-4901
Mailing Address - Street 1:175 SW 7TH ST
Mailing Address - Street 2:SUITE 1710
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2992
Mailing Address - Country:US
Mailing Address - Phone:786-539-4901
Mailing Address - Fax:786-539-4904
Practice Address - Street 1:175 SW 7TH ST
Practice Address - Street 2:SUITE 1710
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-2992
Practice Address - Country:US
Practice Address - Phone:786-539-4901
Practice Address - Fax:786-539-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 2082S0105X, 208D00000X
FLHCC8118261QM1300X
FLOSR 674261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty