=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548844756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLAWLESS FILLERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2021
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 OAK SPRINGS DR UNIT 1
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78702-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-381-8193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2810 OAK SPRINGS DR UNIT 1
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78702-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-381-8193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CRYSTAL UCHIDA
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 803-381-8193
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------