Healthcare Provider Details

I. General information

NPI: 1649401563
Provider Name (Legal Business Name): MEDICAL LASER CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 PLAZA DR SUITE 3
BEREA KY
40403-2087
US

IV. Provider business mailing address

133 PLAZA DR SUITE 3
BEREA KY
40403-2087
US

V. Phone/Fax

Practice location:
  • Phone: 859-986-1370
  • Fax: 859-986-1374
Mailing address:
  • Phone: 859-986-1370
  • Fax: 859-986-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. NAWAR SODA
Title or Position: OWNER
Credential: MD
Phone: 859-986-1370