Provider Demographics
NPI:1215584958
Name:111 AESTHETICS
Entity Type:Organization
Organization Name:111 AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-972-3686
Mailing Address - Street 1:111 S KNOWLES AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4300
Mailing Address - Country:US
Mailing Address - Phone:321-972-3686
Mailing Address - Fax:407-250-9731
Practice Address - Street 1:111 S KNOWLES AVE STE 201
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4300
Practice Address - Country:US
Practice Address - Phone:321-972-3686
Practice Address - Fax:407-250-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies