Provider Demographics
NPI:1609017011
Name:SOUTHWEST AESTHETICS AND BODY SCULPTURE, LLC
Entity type:Organization
Organization Name:SOUTHWEST AESTHETICS AND BODY SCULPTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-545-9772
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:360-352-0637
Practice Address - Street 1:217 VERTIN BLVD
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8783
Practice Address - Country:US
Practice Address - Phone:815-545-9772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1371174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088162Medicaid
IL036065985Medicaid
ILP00870505OtherRR MEDICARE PALMETTO GBA
IL036087434Medicaid
ILP00870409OtherRR MEDICARE PALMETTO GBA
ILDQ7598OtherRR MEDICARE PALMETTO GBA
IL036053917Medicaid
ILG30922Medicare UPIN
ILIL2127007Medicare PIN
ILP00870505OtherRR MEDICARE PALMETTO GBA
ILIL2127003Medicare PIN
ILDQ7598OtherRR MEDICARE PALMETTO GBA
ILE10695Medicare UPIN
ILIL2127005Medicare PIN
ILIL2127001Medicare PIN
ILK51606Medicare UPIN
IL036087434Medicaid
ILG88633Medicare UPIN
ILG68537Medicare UPIN
IL036053917Medicaid
ILIL2127002Medicare PIN