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General NPI Number Information
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NPI Number | 1386223683
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Entity Type | Organization
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Legal Business Name | TKO AESTHESIA
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Dates
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Enumeration Date | 04/05/2021
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Last Update Date | 04/05/2021
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Provider Practice Location Address
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Address Line | 754 S MAIN ST STE 3&4
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City | SAINT GEORGE
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State | UT
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Zip | 84770-5504
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Country | US
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Telephone | 435-628-2671
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 N 2200 W
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City | SAINT GEORGE
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State | UT
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Zip | 84770-5756
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Country | US
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Telephone | 435-773-5585
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JACK BRADLEY WATERS
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Credential | APRN-CRNA
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Telephone | 435-773-5585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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