Healthcare Provider Details

I. General information

NPI: 1790714525
Provider Name (Legal Business Name): PLASTIC SURGERY CENTER OF MERIDIAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5002 HWY 30 NORTH BLDG. D
MERIDIAN MS
39301
US

IV. Provider business mailing address

11999 SAN VICENTE BLVD STE. 440
LOS ANGELES CA
90049-5131
US

V. Phone/Fax

Practice location:
  • Phone: 601-481-7070
  • Fax:
Mailing address:
  • Phone: 310-440-3131
  • Fax: 310-472-9582

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. LEE THORTON
Title or Position: OWNER
Credential: M.D.
Phone: 601-481-7070