Provider Demographics
NPI:1154363752
Name:AESTHETICA MEDICAL SPA LLC
Entity type:Organization
Organization Name:AESTHETICA MEDICAL SPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-562-2275
Mailing Address - Street 1:200 WEST 34TH AVENUE PMB 1008
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5650
Mailing Address - Country:US
Mailing Address - Phone:907-350-9110
Mailing Address - Fax:907-563-7929
Practice Address - Street 1:135 W DIMOND BLVD STE 104
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1907
Practice Address - Country:US
Practice Address - Phone:907-562-2275
Practice Address - Fax:907-563-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK432761207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK160489Medicare ID - Type Unspecified