Provider Demographics
NPI:1609535251
Name:BEAUTY MARK AESTHETICS
Entity Type:Organization
Organization Name:BEAUTY MARK AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONSALES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:937-867-7700
Mailing Address - Street 1:4801 DEER CRK
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-5805
Mailing Address - Country:US
Mailing Address - Phone:937-867-7700
Mailing Address - Fax:
Practice Address - Street 1:866 E FRANKLIN ST STE C
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-5608
Practice Address - Country:US
Practice Address - Phone:937-867-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-10
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center