MEDICARE: ELLIE'S AESTHETICS LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1811827306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLIE'S AESTHETICS LLC

Provider Business Mailing Address
First Line	:	3462 WHITE HOUSE DR SE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-3678
Country	:	US
Telephone Number	:	505-977-6375
Fax Number	:

Provider Business Practice Location Address
First Line	:	3462 WHITE HOUSE DR SE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-3678
Country	:	US
Telephone Number	:	505-977-6375
Fax Number	:

Authorized Official
Title or Position	:	CNP
Name	:	ELLIE HARVEY
Credential	:	CNP
Telephone Number	:	505-977-6375

Provider Enumeration Date	:	05/19/2026
Last Update Date	:	05/19/2026

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