Provider Demographics
NPI:1871051383
Name:SKIN DEEP AESTHETICS, LLC
Entity type:Organization
Organization Name:SKIN DEEP AESTHETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAUSTO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:480-980-1968
Mailing Address - Street 1:1714 W GUADALUPE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-2943
Mailing Address - Country:US
Mailing Address - Phone:480-980-1968
Mailing Address - Fax:
Practice Address - Street 1:1714 W GUADALUPE RD STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-2943
Practice Address - Country:US
Practice Address - Phone:480-980-1968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty