MEDICARE: RENEW WELLNESS AESTHETICS PLLC

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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1295418705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW WELLNESS AESTHETICS PLLC

Provider Business Mailing Address
First Line	:	6141 93RD ST SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-2401
Country	:	US
Telephone Number	:	253-584-3838
Fax Number	:

Provider Business Practice Location Address
First Line	:	6141 93RD ST SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-2401
Country	:	US
Telephone Number	:	253-584-3838
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. ERIK MATTHEW WELLS
Credential	:	DC
Telephone Number	:	253-232-9787

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	08/10/2023

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