Healthcare Provider Details

I. General information

NPI: 1376797332
Provider Name (Legal Business Name): RENUE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 STARLING ST SUITE 604
BRUNSWICK GA
31520-4265
US

IV. Provider business mailing address

2500 STARLING ST SUITE 604
BRUNSWICK GA
31520-4265
US

V. Phone/Fax

Practice location:
  • Phone: 912-280-9977
  • Fax: 912-280-9995
Mailing address:
  • Phone: 912-280-9977
  • Fax: 912-280-9995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number063-383
License Number StateGA

VIII. Authorized Official

Name: DR. CHARLES WILLIAM MITCHELL
Title or Position: MANAGER
Credential: MD
Phone: 912-280-9977