Organization
MEDSPA BY SOUL SURGERY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REGINA SHAKESPEARE (BILLING COMPLIANCE OFFICER)
(928) 554-5633
Entity
Organization
Contact information
Practice address
14362 N FRANK LLOYD WRIGHT BLVD STE B109, SCOTTSDALE, AZ 85260-8881
(480) 912-3105
(480) 912-3106
Mailing address
14362 N FRANK LLOYD WRIGHT BLVD STE B109, SCOTTSDALE, AZ 85260-8881
(480) 912-3105
(480) 912-3106
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
XT4080190
AZ
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
Other
Enumeration date
08/21/2018
Last updated
01/31/2020
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