=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588405971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR SKIN CARE AND ELECTROLYSIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2024
-----------------------------------------------------
Last Update Date | 06/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 148 LINDEN ST STE B2
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02482-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-913-2373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 N MAIN ST # A
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-913-2373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ ELECTROLOGIST
-----------------------------------------------------
Name | SVETLANA SHNAYDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-913-2373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------