Provider Demographics
NPI:1861260671
Name:VIVID AESTHETICS & WELLNESS PLLC
Entity type:Organization
Organization Name:VIVID AESTHETICS & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:SELMA
Authorized Official - Middle Name:COSTA
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-250-9017
Mailing Address - Street 1:110 COURT ST
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-1273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 COURT ST
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-1273
Practice Address - Country:US
Practice Address - Phone:860-250-9017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-12
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty