MEDICARE: AESTHETIC CONCEPTS 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	363LF0000X	Family Nurse Practitioner	NP 669-A	ID

General Provider Information

NPI Number	:	1871734293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC CONCEPTS LLC

Provider Business Mailing Address
First Line	:	2860 CHANNING WAY STE 224
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7541
Country	:	US
Telephone Number	:	208-529-6430
Fax Number	:	208-529-6428

Provider Business Practice Location Address
First Line	:	2860 CHANNING WAY STE 224
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7541
Country	:	US
Telephone Number	:	208-529-6430
Fax Number	:	208-529-6428

Authorized Official
Title or Position	:	OWNER NURSE PRACTITIONER
Name	:	MS. LISA JUNE ZAJANC
Credential	:	MSN FNP-C
Telephone Number	:	208-529-6430

Provider Enumeration Date	:	03/13/2009
Last Update Date	:	03/13/2009

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