Healthcare Provider Details

I. General information

NPI: 1366892952
Provider Name (Legal Business Name): MAINESTATE SURGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 SHIRE VILLAGE DR
SUGAR HILL GA
30518-2922
US

IV. Provider business mailing address

1720 SHIRE VILLAGE DR
SUGAR HILL GA
30518-2922
US

V. Phone/Fax

Practice location:
  • Phone: 678-332-8596
  • Fax:
Mailing address:
  • Phone: 678-332-8596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number16052680
License Number StateGA

VIII. Authorized Official

Name: MR. VERNON GEORGE ROUZEAU-SAUNDERS
Title or Position: CEO
Credential: RN, RNFA
Phone: 678-332-8596