Provider Demographics
NPI:1902452360
Name:ELITE AESTHETICS
Entity Type:Organization
Organization Name:ELITE AESTHETICS
Other - Org Name:ELITE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:409-719-8846
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-0871
Mailing Address - Country:US
Mailing Address - Phone:409-719-8846
Mailing Address - Fax:575-888-2273
Practice Address - Street 1:1005 S TELSHOR BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4879
Practice Address - Country:US
Practice Address - Phone:575-262-7546
Practice Address - Fax:575-888-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty