Healthcare Provider Details

I. General information

NPI: 1821397654
Provider Name (Legal Business Name): RENUE SURGERY CENTER OF WAYCROSS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 TEBEAU ST
WAYCROSS GA
31501-6356
US

IV. Provider business mailing address

PO BOX 2198
BRUNSWICK GA
31521-2198
US

V. Phone/Fax

Practice location:
  • Phone: 912-280-9977
  • Fax: 912-280-9995
Mailing address:
  • Phone: 912-280-9977
  • Fax: 912-280-9995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES WILLIAM MITCHELL
Title or Position: MANAGER
Credential: M.D.
Phone: 912-280-9977