MEDICARE: YUMA WELLNESS & AESTHETICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization
2	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1073399929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YUMA WELLNESS & AESTHETICS

Provider Business Mailing Address
First Line	:	3643 W LIVINGSTON ESTATES CT
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85365-7985
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1455 W 16TH ST STE A
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-8921
Country	:	US
Telephone Number	:	928-510-0899
Fax Number	:	928-447-2501

Authorized Official
Title or Position	:	OWNER
Name	:	AMANDA GRAHAM
Credential	:
Telephone Number	:	928-210-3767

Provider Enumeration Date	:	09/06/2023
Last Update Date	:	03/06/2024

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