Provider Demographics
NPI:1174920789
Name:SOUTHERN OREGON AESTHETICS AND WELLNESS, LLC
Entity type:Organization
Organization Name:SOUTHERN OREGON AESTHETICS AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:A
Authorized Official - Last Name:NOYES
Authorized Official - Suffix:
Authorized Official - Credentials:F-NP/RNFA
Authorized Official - Phone:541-840-8487
Mailing Address - Street 1:5005 TOLO RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-9335
Mailing Address - Country:US
Mailing Address - Phone:760-731-0313
Mailing Address - Fax:760-731-0414
Practice Address - Street 1:5005 TOLO RD
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-9335
Practice Address - Country:US
Practice Address - Phone:760-731-0313
Practice Address - Fax:760-731-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850143NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098000578RNOtherRN FIRST ASSISTANT