Provider Demographics
NPI:1215490628
Name:TOTAL BODY AESTHETIC
Entity type:Organization
Organization Name:TOTAL BODY AESTHETIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KINDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED RN
Authorized Official - Phone:209-207-4980
Mailing Address - Street 1:1525 MESA VERDE DR E STE 214
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5219
Mailing Address - Country:US
Mailing Address - Phone:562-881-8459
Mailing Address - Fax:
Practice Address - Street 1:1525 MESA VERDE DR E STE 214
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5219
Practice Address - Country:US
Practice Address - Phone:833-665-2639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health