Healthcare Provider Details

I. General information

NPI: 1124273685
Provider Name (Legal Business Name): AESTHETIC ARTISTRY SURGICAL AND MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 IRON POINT RD
FOLSOM CA
95630-8838
US

IV. Provider business mailing address

2220 E BIDWELL ST
FOLSOM CA
95630-3546
US

V. Phone/Fax

Practice location:
  • Phone: 916-983-9895
  • Fax: 916-983-9850
Mailing address:
  • Phone: 916-983-9895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA63302
License Number StateCA

VIII. Authorized Official

Name: LISA BOWMAN
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 208-559-7417