Healthcare Provider Details

I. General information

NPI: 1174655880
Provider Name (Legal Business Name): MEDICAL COSMETIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7145 E VIRGINIA ST SUITE 2000
EVANSVILLE IN
47715-9124
US

IV. Provider business mailing address

7145 E VIRGINIA ST SUITE 2000
EVANSVILLE IN
47715-9124
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-6161
  • Fax: 812-476-6162
Mailing address:
  • Phone: 812-476-6161
  • Fax: 812-476-6162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01062143A
License Number StateIN

VIII. Authorized Official

Name: LISA HASTETTER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 812-476-6161