Healthcare Provider Details

I. General information

NPI: 1093792681
Provider Name (Legal Business Name): COSMETIC SURGERY CENTER OF ARDMORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 16TH AVE NW
ARDMORE OK
73401-1818
US

IV. Provider business mailing address

818 16TH AVE NW
ARDMORE OK
73401-1818
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-2171
  • Fax: 580-226-2772
Mailing address:
  • Phone: 580-226-2171
  • Fax: 580-226-2772

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. HARRY GALOOB
Title or Position: OWNER
Credential: M.D.
Phone: 580-226-2171