Provider Demographics
NPI:1811135809
Name:ADVANCED AESTHETICS & WELLNESS CENTER PA, EARLMD FAMILY MEDICINE PA
Entity type:Organization
Organization Name:ADVANCED AESTHETICS & WELLNESS CENTER PA, EARLMD FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:EARL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-273-1426
Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-1638
Mailing Address - Country:US
Mailing Address - Phone:479-876-6077
Mailing Address - Fax:479-271-6805
Practice Address - Street 1:909 SE 28TH ST
Practice Address - Street 2:SUITE 9
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3880
Practice Address - Country:US
Practice Address - Phone:479-273-1426
Practice Address - Fax:479-271-6805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty