Healthcare Provider Details

I. General information

NPI: 1861933582
Provider Name (Legal Business Name): REFRESH ME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CHURCH ST
LAGRANGE GA
30240-2700
US

IV. Provider business mailing address

307 CHURCH ST
LAGRANGE GA
30240-2700
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-3263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberGAD009828
License Number StateGA

VIII. Authorized Official

Name: CHARLES PITTS
Title or Position: OWNER
Credential:
Phone: 706-884-3263