Provider Demographics
NPI:1487946448
Name:WELLNESS AND AESTHETICS INSTITUTE, PA
Entity type:Organization
Organization Name:WELLNESS AND AESTHETICS INSTITUTE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOTSANIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-481-6342
Mailing Address - Street 1:2020 W STATE HIGHWAY 114
Mailing Address - Street 2:SUITE 260
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8649
Mailing Address - Country:US
Mailing Address - Phone:817-481-6342
Mailing Address - Fax:817-442-4848
Practice Address - Street 1:2020 W STATE HIGHWAY 114
Practice Address - Street 2:SUITE 260
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8649
Practice Address - Country:US
Practice Address - Phone:817-481-6342
Practice Address - Fax:817-442-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5951207K00000X, 207RX0202X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty