Provider Demographics
NPI:1023358488
Name:AESTHETIQUE, COSMETIC AND LASER SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:AESTHETIQUE, COSMETIC AND LASER SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUREDDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-264-6334
Mailing Address - Street 1:10 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2260
Mailing Address - Country:US
Mailing Address - Phone:203-264-6334
Mailing Address - Fax:203-267-7654
Practice Address - Street 1:10 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2260
Practice Address - Country:US
Practice Address - Phone:203-264-6334
Practice Address - Fax:203-267-7654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty