1609017011 NPI number — SOUTHWEST AESTHETICS AND BODY SCULPTURE, LLC

Table of content: (NPI 1609017011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609017011 NPI number — SOUTHWEST AESTHETICS AND BODY SCULPTURE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST AESTHETICS AND BODY SCULPTURE, LLC
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:
1609017011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98508-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-352-2037
Provider Business Mailing Address Fax Number:
360-352-0637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 VERTIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOREWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60404-8783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-545-9772
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHIU
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER MEMBER
Authorized Official Telephone Number:
815-545-9772

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  1371 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036088162 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036065985 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00870505 . This is a "RR MEDICARE PALMETTO GBA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036087434 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00870409 . This is a "RR MEDICARE PALMETTO GBA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DQ7598 . This is a "RR MEDICARE PALMETTO GBA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036053917 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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