MEDICARE: MED AESTHETICS MD, 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	:	1679252068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED AESTHETICS MD, LLC

Provider Business Mailing Address
First Line	:	5925 LEHMAN DR STE 3
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3418
Country	:	US
Telephone Number	:	719-201-7020
Fax Number	:

Provider Business Practice Location Address
First Line	:	5925 LEHMAN DR STE 3
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3418
Country	:	US
Telephone Number	:	719-201-7020
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JESSICA HAMMOND
Credential	:
Telephone Number	:	719-201-7020

Provider Enumeration Date	:	07/13/2023
Last Update Date	:	07/13/2023

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