Provider Demographics
NPI:1902298243
Name:AUMBRIA HEALTH AND AESTHETICS LLC
Entity Type:Organization
Organization Name:AUMBRIA HEALTH AND AESTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:AMPONG
Authorized Official - Last Name:KODJOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-241-8721
Mailing Address - Street 1:1301 BERTHA HOWE AVE
Mailing Address - Street 2:STE# 2
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-7502
Mailing Address - Country:US
Mailing Address - Phone:702-345-3312
Mailing Address - Fax:702-345-3374
Practice Address - Street 1:1301 BERTHA HOWE AVE
Practice Address - Street 2:STE# 2
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7502
Practice Address - Country:US
Practice Address - Phone:702-345-3312
Practice Address - Fax:702-345-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20151021732OtherNV SECRETARY OF STATE