Provider Demographics
NPI:1164953998
Name:FULLCIRCLE AESTHETICS LLC.
Entity Type:Organization
Organization Name:FULLCIRCLE AESTHETICS LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:215-740-4213
Mailing Address - Street 1:125 FOREST AVE
Mailing Address - Street 2:APT 8-C
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-5934
Mailing Address - Country:US
Mailing Address - Phone:215-740-4213
Mailing Address - Fax:
Practice Address - Street 1:125 FOREST AVE
Practice Address - Street 2:APT 8-C
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-5934
Practice Address - Country:US
Practice Address - Phone:215-740-4213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005039302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization