Healthcare Provider Details

I. General information

NPI: 1962960146
Provider Name (Legal Business Name): ELITE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 4TH AVE CIRCLE E
BRADENTON FL
34208
US

IV. Provider business mailing address

5301 4TH AVE CIRCLE E
BRADENTON FL
34208
US

V. Phone/Fax

Practice location:
  • Phone: 941-954-4500
  • Fax:
Mailing address:
  • Phone: 941-954-4500
  • 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: MELINDA L LACERNA KIMBRELL
Title or Position: MANAGER/MEMBER
Credential: M.D.
Phone: 941-954-4500