=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861270324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FACE IT - AESTHETICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6729 4TH ST NW
-----------------------------------------------------
City | LOS RANCHOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-6114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-400-7339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6917 2ND ST NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-400-7339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER/ OWNER
-----------------------------------------------------
Name | CHRISTINE MARIE MAYES
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 505-400-7339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------