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General NPI Number Information
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NPI Number | 1427755339
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Entity Type | Organization
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Legal Business Name | BRICK CITY AESTHETICS LLC
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Dates
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Enumeration Date | 02/10/2023
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Last Update Date | 02/10/2023
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Provider Practice Location Address
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Address Line | 328 S BONAVENTURE AVE STE 2
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City | TRINIDAD
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State | CO
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Zip | 81082-2086
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Country | US
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Telephone | 719-680-3509
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Fax |
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Provider Business Mailing Address
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Address Line | 215 CORUNDUM RD
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City | TRINIDAD
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State | CO
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Zip | 81082-9413
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Country | US
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Telephone | 719-680-3509
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/CO-OWNER
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Name | DARIO BYUNG SAN ROMAN
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Credential | NP
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Telephone | 719-289-1139
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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