Provider Demographics
NPI:1518611904
Name:AESTHETIC LUXURY SPA LLC
Entity Type:Organization
Organization Name:AESTHETIC LUXURY SPA LLC
Other - Org Name:AESTHETIC LUXURY SPA LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LASHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-577-1200
Mailing Address - Street 1:17201 E 40 HWY STE 114
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6437
Mailing Address - Country:US
Mailing Address - Phone:816-886-2227
Mailing Address - Fax:816-886-2227
Practice Address - Street 1:2321 TROOST AVE STE 101
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2834
Practice Address - Country:US
Practice Address - Phone:816-200-2409
Practice Address - Fax:816-320-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-05
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO863097642Medicaid