Provider Demographics
NPI:1336454263
Name:TOTAL BODY AESTHETICS, INC.
Entity Type:Organization
Organization Name:TOTAL BODY AESTHETICS, INC.
Other - Org Name:TOTAL BODY HEALTH & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:LME
Authorized Official - Phone:904-472-5563
Mailing Address - Street 1:4540 SOUTHSIDE BLVD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5492
Mailing Address - Country:US
Mailing Address - Phone:904-472-5563
Mailing Address - Fax:904-435-4051
Practice Address - Street 1:4540 SOUTHSIDE BLVD
Practice Address - Street 2:SUITE 701
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5492
Practice Address - Country:US
Practice Address - Phone:904-472-5563
Practice Address - Fax:904-435-4051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFB9712840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty