Provider Demographics
NPI:1336982891
Name:AESTHETIC REPOSITORY
Entity type:Organization
Organization Name:AESTHETIC REPOSITORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-445-9353
Mailing Address - Street 1:400 N 1ST ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N 1ST ST STE 104
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1361
Practice Address - Country:US
Practice Address - Phone:612-445-9353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No251J00000XAgenciesNursing Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No332900000XSuppliersNon-Pharmacy Dispensing Site