Provider Demographics
NPI:1861735847
Name:SOL MED SPA
Entity type:Organization
Organization Name:SOL MED SPA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:JESUS
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-735-1712
Mailing Address - Street 1:720 MAGNOLIA AVE
Mailing Address - Street 2:STE. B-1
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3119
Mailing Address - Country:US
Mailing Address - Phone:951-735-1712
Mailing Address - Fax:951-735-1094
Practice Address - Street 1:716 E MISSION BLVD
Practice Address - Street 2:STE. D
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-7203
Practice Address - Country:US
Practice Address - Phone:909-865-2332
Practice Address - Fax:909-868-7129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty