Provider Demographics
NPI:1427755339
Name:BRICK CITY AESTHETICS LLC
Entity type:Organization
Organization Name:BRICK CITY AESTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARIO
Authorized Official - Middle Name:BYUNG
Authorized Official - Last Name:SAN ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:719-289-1139
Mailing Address - Street 1:215 CORUNDUM RD
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-9413
Mailing Address - Country:US
Mailing Address - Phone:719-680-3509
Mailing Address - Fax:
Practice Address - Street 1:328 S BONAVENTURE AVE STE 2
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2086
Practice Address - Country:US
Practice Address - Phone:719-680-3509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty