Provider Demographics
NPI:1962441709
Name:ADVANCED AESTHETICS PC
Entity Type:Organization
Organization Name:ADVANCED AESTHETICS PC
Other - Org Name:ADVANCED AESTHETICS PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-461-4000
Mailing Address - Street 1:874 W LANIER AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7659
Mailing Address - Country:US
Mailing Address - Phone:770-461-4000
Mailing Address - Fax:770-461-2790
Practice Address - Street 1:874 W LANIER AVE
Practice Address - Street 2:STE 110
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7659
Practice Address - Country:US
Practice Address - Phone:770-461-4000
Practice Address - Fax:770-461-2790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED AESTHETICS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-06
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical