Healthcare Provider Details

I. General information

NPI: 1821209909
Provider Name (Legal Business Name): FACIAL & AESTHETIC PLASTIC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 MARKET ST SUITE A103B
BOARDMAN OH
44512-3457
US

IV. Provider business mailing address

6505 MARKET ST SUITE A103B
BOARDMAN OH
44512-3457
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-0191
  • Fax: 330-726-3577
Mailing address:
  • Phone: 330-758-0191
  • Fax: 330-726-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD D GENTILE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 330-758-0191