Healthcare Provider Details

I. General information

NPI: 1659139590
Provider Name (Legal Business Name): MAGNOLIA LANE PLASTIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD STE 110
AUGUSTA GA
30909-6544
US

IV. Provider business mailing address

607 RONALD REAGAN DR UNIT 724
EVANS GA
30809-7729
US

V. Phone/Fax

Practice location:
  • Phone: 706-723-1632
  • Fax: 706-869-3841
Mailing address:
  • Phone:
  • 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: MRS. TAYLOR CATO
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-723-1632