MEDICARE: RELLA AESTHETICS, INC

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	:	1841069812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELLA AESTHETICS, INC

Provider Business Mailing Address
First Line	:	542 MAIN ST
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95688-3912
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	542 MAIN ST
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95688-3912
Country	:	US
Telephone Number	:	707-358-2928
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ZACHARY WAGNER
Credential	:	DO
Telephone Number	:	707-358-2928

Provider Enumeration Date	:	01/01/2024
Last Update Date	:	01/01/2024

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