Provider Demographics
NPI:1023872801
Name:MYTHOLOGY AESTHETICS, LLC
Entity type:Organization
Organization Name:MYTHOLOGY AESTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLATHRAS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:781-795-9595
Mailing Address - Street 1:112 BOWER RD
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-1536
Mailing Address - Country:US
Mailing Address - Phone:781-389-0508
Mailing Address - Fax:
Practice Address - Street 1:10 FORBES RD STE 172E
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2605
Practice Address - Country:US
Practice Address - Phone:781-795-9595
Practice Address - Fax:781-494-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty