Healthcare Provider Details

I. General information

NPI: 1407043755
Provider Name (Legal Business Name): CENTER FOR RESTORATIVE BREAST SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 04/18/2024
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 ST CHARLES AVE
NEW ORLEANS LA
70130
US

IV. Provider business mailing address

PO BOX 8664
METAIRIE LA
70011
US

V. Phone/Fax

Practice location:
  • Phone: 504-899-2800
  • Fax: 504-620-3964
Mailing address:
  • Phone: 504-899-2800
  • Fax: 504-620-3964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number021287
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number024972
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number13291R
License Number StateLA

VIII. Authorized Official

Name: AMY R TRAUB
Title or Position: FINANCE SPECIALIST
Credential:
Phone: 504-529-6679