Healthcare Provider Details

I. General information

NPI: 1639005846
Provider Name (Legal Business Name): AESTHETIC ANTIDOTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 BAILEYVILLE RD
MIDDLEFIELD CT
06455-1014
US

IV. Provider business mailing address

181 MADISON RD
DURHAM CT
06422-2910
US

V. Phone/Fax

Practice location:
  • Phone: 203-903-3513
  • Fax:
Mailing address:
  • Phone: 203-903-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FRANCIS RUIZ
Title or Position: OWNER
Credential: MD
Phone: 203-903-3513