MEDICARE: THE VISAGE OF BEAUTY LLC

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1154265197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VISAGE OF BEAUTY LLC

Provider Business Mailing Address
First Line	:	945 TOWN CENTRE DR STE B
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-6190
Country	:	US
Telephone Number	:	561-381-1704
Fax Number	:

Provider Business Practice Location Address
First Line	:	945 TOWN CENTRE DR STE B
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-6190
Country	:	US
Telephone Number	:	561-381-1704
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CESAR PONCE
Credential	:
Telephone Number	:	561-381-1704

Provider Enumeration Date	:	04/20/2026
Last Update Date	:	04/20/2026

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Directions to “THE VISAGE OF BEAUTY LLC ” Practice Location

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