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General NPI Number Information
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NPI Number | 1164953998
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Entity Type | Organization
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Legal Business Name | FULLCIRCLE AESTHETICS LLC.
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Dates
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Enumeration Date | 03/23/2017
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Last Update Date | 03/23/2017
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Provider Practice Location Address
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Address Line | 125 FOREST AVE APT 8-C
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City | AMBLER
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State | PA
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Zip | 19002-5934
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Country | US
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Telephone | 215-740-4213
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Fax |
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Provider Business Mailing Address
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Address Line | 125 FOREST AVE APT 8-C
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City | AMBLER
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State | PA
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Zip | 19002-5934
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Country | US
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Telephone | 215-740-4213
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Fax |
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Authorized Official
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Title or Position | OWER
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Name | TIFFANY S. FENNELL
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Credential | L.M.T.
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Telephone | 215-740-4213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | MSG005039
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License Number State | PA
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