Healthcare Provider Details

I. General information

NPI: 1326710526
Provider Name (Legal Business Name): INFUSE AESTHETICS AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 E SHOTWELL ST
BAINBRIDGE GA
39819-4063
US

IV. Provider business mailing address

114 PINE BLOOM DR
BAINBRIDGE GA
39819-6540
US

V. Phone/Fax

Practice location:
  • Phone: 229-400-9260
  • Fax:
Mailing address:
  • Phone: 229-220-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRITTNEY LONDON TYUS
Title or Position: OWNER
Credential: NP
Phone: 229-220-7755