Provider Demographics
NPI:1184231979
Name:AURORA AESTHETICS AND FUNCTIONAL MEDICINE CLINIC, PLLC
Entity Type:Organization
Organization Name:AURORA AESTHETICS AND FUNCTIONAL MEDICINE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FRIESS
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-350-7228
Mailing Address - Street 1:713 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1478
Mailing Address - Country:US
Mailing Address - Phone:907-350-7228
Mailing Address - Fax:
Practice Address - Street 1:713 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1478
Practice Address - Country:US
Practice Address - Phone:907-350-7228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care