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General NPI Number Information
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NPI Number | 1649509258
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Entity Type | Organization
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Legal Business Name | XTRIM MED SPA
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Dates
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Enumeration Date | 12/09/2009
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Last Update Date | 12/09/2009
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Provider Practice Location Address
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Address Line | 2915 E BASELINE RD SUITE 107
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City | GILBERT
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State | AZ
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Zip | 85234-2425
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Country | US
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Telephone | 480-507-8181
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Fax |
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Provider Business Mailing Address
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Address Line | 1757 E BASELINE RD SUITE 137
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City | GILBERT
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State | AZ
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Zip | 85233-1532
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RENO EDGINGTON
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Credential |
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Telephone | 480-634-7601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 33677
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License Number State | AZ
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