MEDICARE: SKINIQUE MED SPA & WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist

General Provider Information

NPI Number	:	1215313259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKINIQUE MED SPA & WELLNESS

Provider Business Mailing Address
First Line	:	3160 N TARRANT PKWY STE 404
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8614
Country	:	US
Telephone Number	:	817-484-0300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3160 N TARRANT PKWY STE 404
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8614
Country	:	US
Telephone Number	:	817-484-0300
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. MARK CHARLIE VALENTE
Credential	:	D.O.
Telephone Number	:	817-484-0300

Provider Enumeration Date	:	07/31/2015
Last Update Date	:	07/31/2015

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