Provider Demographics
NPI:1386223683
Name:TKO AESTHESIA
Entity Type:Organization
Organization Name:TKO AESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CRNA
Authorized Official - Phone:435-773-5585
Mailing Address - Street 1:1401 N 2200 W
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5756
Mailing Address - Country:US
Mailing Address - Phone:435-773-5585
Mailing Address - Fax:
Practice Address - Street 1:754 S MAIN ST STE 3&4
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5504
Practice Address - Country:US
Practice Address - Phone:435-628-2671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center