Healthcare Provider Details

I. General information

NPI: 1700878576
Provider Name (Legal Business Name): STANISLAW FACIAL PLASTIC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 NOD RD SUITE 204
AVON CT
06001-3826
US

IV. Provider business mailing address

35 NOD RD SUITE 204
AVON CT
06001-3826
US

V. Phone/Fax

Practice location:
  • Phone: 860-409-1515
  • Fax:
Mailing address:
  • Phone: 860-409-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL STANISLAW JR.
Title or Position: OWNER
Credential: MD
Phone: 860-409-1515