Healthcare Provider Details

I. General information

NPI: 1063096618
Provider Name (Legal Business Name): CUTTING EDGE SURGICAL ASSISTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 S VILLAGE SQ
CANTON GA
30115-1861
US

IV. Provider business mailing address

266 S VILLAGE SQ
CANTON GA
30115-1861
US

V. Phone/Fax

Practice location:
  • Phone: 770-851-3123
  • Fax:
Mailing address:
  • Phone: 770-851-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: TOMMY LARSON
Title or Position: OWNER
Credential: CSFA
Phone: 770-851-3123