MEDICARE: TKO AESTHESIA

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1386223683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TKO AESTHESIA

Provider Business Mailing Address
First Line	:	1401 N 2200 W
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-5756
Country	:	US
Telephone Number	:	435-773-5585
Fax Number	:

Provider Business Practice Location Address
First Line	:	754 S MAIN ST STE 3&4
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-5504
Country	:	US
Telephone Number	:	435-628-2671
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JACK BRADLEY WATERS
Credential	:	APRN-CRNA
Telephone Number	:	435-773-5585

Provider Enumeration Date	:	04/05/2021
Last Update Date	:	04/05/2021

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Directions to “TKO AESTHESIA ” Practice Location

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