Healthcare Provider Details

I. General information

NPI: 1447541230
Provider Name (Legal Business Name): MEDICAL AESTHETIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 05/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CINEMA LANE SUITE 140
SAINT SIMONS ISLAND GA
31522-6631
US

IV. Provider business mailing address

60 CINEMA LANE SUITE 140
SAINT SIMONS ISLAND GA
31522-6631
US

V. Phone/Fax

Practice location:
  • Phone: 912-638-7799
  • Fax: 912-638-7755
Mailing address:
  • Phone: 912-638-7799
  • Fax: 912-638-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number058102
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number058102
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL CAL PINELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 912-638-7799