Provider Demographics
NPI:1467098434
Name:D ESTHETIQUE COSMETIC &LASER CENTER
Entity Type:Organization
Organization Name:D ESTHETIQUE COSMETIC &LASER CENTER
Other - Org Name:D ESTHETIQUE MEDICAL AESTHETICS & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:FAMILY NURSE PRACTIT
Authorized Official - Phone:940-692-1706
Mailing Address - Street 1:3916 CALLFIELD ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308
Mailing Address - Country:US
Mailing Address - Phone:940-692-1706
Mailing Address - Fax:940-687-1794
Practice Address - Street 1:3916 CALLFIELD ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308
Practice Address - Country:US
Practice Address - Phone:940-692-1706
Practice Address - Fax:940-687-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1568414753OtherNPI NUMBER