1811135809 NPI number — ADVANCED AESTHETICS & WELLNESS CENTER PA, EARLMD FAMILY MEDICINE PA

Table of content: (NPI 1811135809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811135809 NPI number — ADVANCED AESTHETICS & WELLNESS CENTER PA, EARLMD FAMILY MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED AESTHETICS & WELLNESS CENTER PA, EARLMD FAMILY MEDICINE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811135809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72745-1638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-876-6077
Provider Business Mailing Address Fax Number:
479-271-6805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 SE 28TH ST
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
BENTONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72712-3880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-273-1426
Provider Business Practice Location Address Fax Number:
479-271-6805
Provider Enumeration Date:
01/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EARL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
SAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-273-1426

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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