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General NPI Number Information
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NPI Number | 1336454263
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Entity Type | Organization
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Legal Business Name | TOTAL BODY AESTHETICS, INC.
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Dates
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Enumeration Date | 08/16/2010
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Last Update Date | 08/16/2010
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Provider Practice Location Address
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Address Line | 4540 SOUTHSIDE BLVD SUITE 701
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5492
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Country | US
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Telephone | 904-472-5563
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Fax | 904-435-4051
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Provider Business Mailing Address
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Address Line | 4540 SOUTHSIDE BLVD SUITE 701
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5492
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Country | US
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Telephone | 904-472-5563
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Fax | 904-435-4051
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MS. STEPHANIE K HUMPHRIES
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Credential | L.M.E.
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Telephone | 904-472-5563
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | FB9712840
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License Number State | FL
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