Healthcare Provider Details

I. General information

NPI: 1174520191
Provider Name (Legal Business Name): AESTHETIC SURGERY CENTER OF EUGENE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 WILLAKENZIE RD
EUGENE OR
97401-7865
US

IV. Provider business mailing address

2550 WILLAKENZIE RD
EUGENE OR
97401-7865
US

V. Phone/Fax

Practice location:
  • Phone: 541-434-0922
  • Fax: 541-434-4369
Mailing address:
  • Phone: 541-434-0922
  • Fax: 541-434-4369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number071545
License Number StateOR

VIII. Authorized Official

Name: BLAKE V FAUSETT
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: MD, PHD
Phone: 541-434-0922