Provider Demographics
NPI:1104503390
Name:SKIN INVY ESTHETICS & MASSAGE SALON LLC
Entity type:Organization
Organization Name:SKIN INVY ESTHETICS & MASSAGE SALON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT/OWNER/EMPLOYEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:CLOTELIA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, LPN, ACLP, LE
Authorized Official - Phone:706-829-8038
Mailing Address - Street 1:3540 WHEELER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1876
Mailing Address - Country:US
Mailing Address - Phone:706-828-9803
Mailing Address - Fax:706-496-8541
Practice Address - Street 1:3540 WHEELER RD STE 107
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1876
Practice Address - Country:US
Practice Address - Phone:706-829-8038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-29
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty