Provider Demographics
NPI:1194199760
Name:SOUTH TEXAS MEDSPA LLC
Entity Type:Organization
Organization Name:SOUTH TEXAS MEDSPA LLC
Other - Org Name:SLIMEDICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-662-4014
Mailing Address - Street 1:14615 SAN PEDRO AVE
Mailing Address - Street 2:120
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4321
Mailing Address - Country:US
Mailing Address - Phone:210-971-4000
Mailing Address - Fax:
Practice Address - Street 1:14615 SAN PEDRO AVE
Practice Address - Street 2:120
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4321
Practice Address - Country:US
Practice Address - Phone:210-971-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty