Healthcare Provider Details

I. General information

NPI: 1013298751
Provider Name (Legal Business Name): AETHETIC ARTS INSTITUTE OF PLASTIC SURGERY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 GRANT AVE
LA MESA CA
91941-5303
US

IV. Provider business mailing address

8401 GRANT AVE.
LA MESA CA
91941
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-9876
  • Fax: 619-464-9877
Mailing address:
  • Phone: 619-464-9876
  • Fax: 619-464-9877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number05C0001125
License Number StateCA

VIII. Authorized Official

Name: DR. SUSAN KAWESKI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 619-464-9876