Provider Demographics
NPI:1124881693
Name:SO ESTHEVA WELLNESS MEDSPA LLC
Entity type:Organization
Organization Name:SO ESTHEVA WELLNESS MEDSPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:LUST
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:330-635-2782
Mailing Address - Street 1:1447 RUMBAUGH CIR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-3009
Mailing Address - Country:US
Mailing Address - Phone:306-352-7823
Mailing Address - Fax:
Practice Address - Street 1:5730 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1146
Practice Address - Country:US
Practice Address - Phone:330-846-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service