Healthcare Provider Details

I. General information

NPI: 1386223683
Provider Name (Legal Business Name): TKO AESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 S MAIN ST STE 3&4
SAINT GEORGE UT
84770-5504
US

IV. Provider business mailing address

1401 N 2200 W
SAINT GEORGE UT
84770-5756
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-2671
  • Fax:
Mailing address:
  • Phone: 435-773-5585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACK BRADLEY WATERS
Title or Position: MANAGER
Credential: APRN-CRNA
Phone: 435-773-5585