Healthcare Provider Details

I. General information

NPI: 1093939894
Provider Name (Legal Business Name): MOUNTAIN BROOK PLASTIC SURGERY AND LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 CAHABA RD SUITE 100
BIRMINGHAM AL
35223-2346
US

IV. Provider business mailing address

2850 CAHABA RD SUITE 100
BIRMINGHAM AL
35223-2346
US

V. Phone/Fax

Practice location:
  • Phone: 205-871-4440
  • Fax: 205-871-7776
Mailing address:
  • Phone: 205-871-4440
  • Fax: 205-871-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberAL16730
License Number StateAL

VIII. Authorized Official

Name: MRS. LAUREN RIVES
Title or Position: CLINICAL MANAGER
Credential:
Phone: 205-871-4440