Basic Information
| Provider Information | |||||||||
| NPI: | 1114248044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED AESTHETICS AND REJUVINATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5661 LAKE SHORE AVE | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430828174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 30701 LORAIN RD STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440706325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2010 | ||||||||
| LastUpdateDate: | 06/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4402745000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 1402156 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.