Provider Demographics
NPI:1841409281
Name:SO, TX. AESTHETIC ENHANCEMENT CENTER
Entity Type:Organization
Organization Name:SO, TX. AESTHETIC ENHANCEMENT CENTER
Other - Org Name:S.T.A.E.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:POLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-538-6600
Mailing Address - Street 1:2525 S SHORE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2988
Mailing Address - Country:US
Mailing Address - Phone:281-538-6600
Mailing Address - Fax:
Practice Address - Street 1:2525 S SHORE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2988
Practice Address - Country:US
Practice Address - Phone:281-538-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2974261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical