Provider Demographics
NPI:1831719756
Name:ELITE AESTHETICS, LLC
Entity type:Organization
Organization Name:ELITE AESTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:METAKES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:386-682-1687
Mailing Address - Street 1:6 COCONUT ROW
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W 1ST ST STE 236
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1202
Practice Address - Country:US
Practice Address - Phone:386-682-1687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center