Healthcare Provider Details

I. General information

NPI: 1780820381
Provider Name (Legal Business Name): SEASIDE SURGICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303B GLYNN AVE
BRUNSWICK GA
31520-4406
US

IV. Provider business mailing address

3303B GLYNN AVE
BRUNSWICK GA
31520-4406
US

V. Phone/Fax

Practice location:
  • Phone: 912-466-9500
  • Fax: 912-466-9922
Mailing address:
  • Phone: 912-466-9500
  • Fax: 912-466-9922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA J CLARK
Title or Position: OFFICE MANAGER
Credential:
Phone: 912-466-9500