Healthcare Provider Details

I. General information

NPI: 1326408329
Provider Name (Legal Business Name): ADVANCED AESTHETICS OF TEXAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18322 SONTERRA PL STE 107
SAN ANTONIO TX
78258-4196
US

IV. Provider business mailing address

PO BOX 591819
SAN ANTONIO TX
78259-0140
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-5771
  • Fax: 210-966-9105
Mailing address:
  • Phone: 210-495-5771
  • Fax: 210-966-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM2695
License Number StateTX

VIII. Authorized Official

Name: LOPEZ ANTONIO LOPEZ
Title or Position: OWNER
Credential: MD
Phone: 210-495-5771