Provider Demographics
NPI:1437340684
Name:SEASONS MEDICAL AESTHETICS
Entity Type:Organization
Organization Name:SEASONS MEDICAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GOODYEAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-255-3223
Mailing Address - Street 1:921 N TRENTON ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3327
Mailing Address - Country:US
Mailing Address - Phone:318-255-3223
Mailing Address - Fax:318-255-3181
Practice Address - Street 1:411 E VAUGHN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5972
Practice Address - Country:US
Practice Address - Phone:318-255-3223
Practice Address - Fax:318-255-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201086207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA201086OtherMEDICAL LICENSE
LA1453331Medicaid
LA5CX71OtherMEDICARE
LA5CX71OtherMEDICARE