=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497577613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANT ESTHETICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2024
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 BELLEVUE AVE STE C
-----------------------------------------------------
City | NEWPORT
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02840-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-848-0022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 STANDISH RD
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02835-1289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JANA MAGARIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-714-7679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------