Healthcare Provider Details

I. General information

NPI: 1699696328
Provider Name (Legal Business Name): EAST COAST PLASTIC SURGERY OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 GODBY RD
ATLANTA GA
30349-5002
US

IV. Provider business mailing address

2230 GODBY RD
ATLANTA GA
30349-5002
US

V. Phone/Fax

Practice location:
  • Phone: 212-628-7300
  • Fax: 212-628-7302
Mailing address:
  • Phone: 212-628-7300
  • Fax: 212-628-7302

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: MR. MICHAEL MANZO
Title or Position: ACCOUNTS RECEIVABLE MANAGER
Credential:
Phone: 212-628-7300