Provider Demographics
NPI:1215313259
Name:SKINIQUE MED SPA & WELLNESS
Entity type:Organization
Organization Name:SKINIQUE MED SPA & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHARLIE
Authorized Official - Last Name:VALENTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-484-0300
Mailing Address - Street 1:3160 N TARRANT PKWY STE 404
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8614
Mailing Address - Country:US
Mailing Address - Phone:817-484-0300
Mailing Address - Fax:
Practice Address - Street 1:3160 N TARRANT PKWY STE 404
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8614
Practice Address - Country:US
Practice Address - Phone:817-484-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty