Basic Information
| Provider Information | |||||||||
| NPI: | 1386223683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TKO AESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 N 2200 W | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847705756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357735585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 754 S MAIN ST STE 3&4 | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847705504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356282671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2021 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | WATERS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | BRADLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4357735585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN-CRNA | ||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.