MEDICARE: AMBIANCE AESTHETICS & REJUVENATION

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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1932982360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBIANCE AESTHETICS & REJUVENATION

Provider Business Mailing Address
First Line	:	10609 LAND TREE DR
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-6633
Country	:	US
Telephone Number	:	410-299-8955
Fax Number	:

Provider Business Practice Location Address
First Line	:	1667 CROFTON CTR STE 8B
Second Line	:
City	:	CROFTON
State	:	MD
Zip	:	21114-1303
Country	:	US
Telephone Number	:	667-230-3591
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KAREN M JOHNSON
Credential	:	FNP-C
Telephone Number	:	667-230-3591

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	08/17/2023

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