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General NPI Number Information
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NPI Number | 1104446715
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Entity Type | Organization
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Legal Business Name | SKIN THEORY AESTHETICS INC.
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Dates
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Enumeration Date | 04/23/2020
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Last Update Date | 04/23/2020
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Provider Practice Location Address
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Address Line | 2791 GREEN RIVER RD STE 103
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City | CORONA
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State | CA
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Zip | 92882-7452
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Country | US
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Telephone | 951-735-5570
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Fax | 951-735-5572
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Provider Business Mailing Address
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Address Line | 2791 GREEN RIVER RD STE 103
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City | CORONA
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State | CA
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Zip | 92882-7452
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Country | US
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Telephone | 951-735-5570
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Fax | 951-735-5572
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Authorized Official
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Title or Position | OWNER/EMPLOYEE
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Name | SHAUNA MICHELS
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Credential |
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Telephone | 951-735-5570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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