1063635829 NPI number — ESTHETICS UNLIMITED

Table of content: DR. CARLOS FERNANDO LEON MD (NPI 1730153750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063635829 NPI number — ESTHETICS UNLIMITED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESTHETICS UNLIMITED
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:
1063635829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4509 9TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39305-2815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-483-4946
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-483-6021
Provider Business Practice Location Address Fax Number:
601-483-1140
Provider Enumeration Date:
04/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHIRLEY
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
MILES
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
601-483-6021

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3104-99 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 136969 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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