1902084593 NPI number — WINCHESTER AESTHETIC SURGICAL SUITE, SC

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 1902084593 NPI number — WINCHESTER AESTHETIC SURGICAL SUITE, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINCHESTER AESTHETIC SURGICAL SUITE, SC
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:
1902084593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1880 W WINCHESTER RD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-5341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-968-2401
Provider Business Mailing Address Fax Number:
847-968-2402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1880 W WINCHESTER RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-968-2401
Provider Business Practice Location Address Fax Number:
847-968-2402
Provider Enumeration Date:
02/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TIJUNELIS
Authorized Official First Name:
ARAS
Authorized Official Middle Name:
DONATAS
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
847-968-2401

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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