Healthcare Provider Details

I. General information

NPI: 1669177192
Provider Name (Legal Business Name): ELITE AESTHETICS & DERMATOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 CALLOWAY DR UNIT 602
BAKERSFIELD CA
93312-2534
US

IV. Provider business mailing address

3409 CALLOWAY DR UNIT 602
BAKERSFIELD CA
93312-2534
US

V. Phone/Fax

Practice location:
  • Phone: 661-218-9923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER TOUGAS-GENOVA
Title or Position: NURSE PRACTITIONER
Credential: FNP-C
Phone: 413-519-5594