Provider Demographics
NPI:1184104812
Name:MEDSPA BY SOUL SURGERY, LLC
Entity type:Organization
Organization Name:MEDSPA BY SOUL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKESPEARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-554-5633
Mailing Address - Street 1:14362 N FRANK LLOYD WRIGHT BLVD STE B109
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-8881
Mailing Address - Country:US
Mailing Address - Phone:480-912-3105
Mailing Address - Fax:480-912-3106
Practice Address - Street 1:14362 N FRANK LLOYD WRIGHT BLVD STE B109
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-8881
Practice Address - Country:US
Practice Address - Phone:480-912-3105
Practice Address - Fax:480-912-3106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZXT4080190207R00000X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty