Provider Demographics
NPI:1104446715
Name:SKIN THEORY AESTHETICS INC.
Entity type:Organization
Organization Name:SKIN THEORY AESTHETICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-735-5570
Mailing Address - Street 1:2791 GREEN RIVER RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-7452
Mailing Address - Country:US
Mailing Address - Phone:951-735-5570
Mailing Address - Fax:951-735-5572
Practice Address - Street 1:2791 GREEN RIVER RD STE 103
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-7452
Practice Address - Country:US
Practice Address - Phone:951-735-5570
Practice Address - Fax:951-735-5572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841598232OtherINDIVIDUAL NPI