1477584845 NPI number — DEVENIR AESTHETICS, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477584845 NPI number — DEVENIR AESTHETICS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVENIR AESTHETICS, 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:
1477584845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3807 SPICEWOOD SPRINGS RD
Provider Second Line Business Mailing Address:
#201
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-8965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-477-3778
Provider Business Mailing Address Fax Number:
512-477-3626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3807 SPICEWOOD SPRINGS RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-8965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-477-3778
Provider Business Practice Location Address Fax Number:
512-477-3626
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JUAREZ
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
512-477-3778

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45D1003610 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0040HW . This is a "BCBS GROUP" identifier . This identifiers is of the category "OTHER".




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