Organization
EYESTHETICA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK GRISBY (CHIEF EXECUTIVE OFFICER)
(231) 234-1011
Entity
Organization
Contact information
Practice address
625 S FAIR OAKS AVE STE 265, PASADENA, CA 91105-2613
(213) 234-1000
(213) 234-1001
Mailing address
500 MOLINO ST STE 107, LOS ANGELES, CA 90013-2271
(213) 234-1000
(213) 234-1001
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0091240
—
CA
01
—
ZZZ06818Z
MEDICARE PIN; PALM SPRING
CA
Enumeration date
04/13/2007
Last updated
06/24/2022
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