Healthcare Provider Details

I. General information

NPI: 1164700415
Provider Name (Legal Business Name): MARK E LOISELLE CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 LAKEWOOD CT
CANTON GA
30114-6694
US

IV. Provider business mailing address

515 LAKEWOOD CT
CANTON GA
30114-6694
US

V. Phone/Fax

Practice location:
  • Phone: 770-361-0034
  • Fax:
Mailing address:
  • Phone: 770-361-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number200838
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: