Healthcare Provider Details

I. General information

NPI: 1174906648
Provider Name (Legal Business Name): AESTHETIC CENTER FOR BREAST AND COSMETIC SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 HALTON RD
GREENVILLE SC
29607-3403
US

IV. Provider business mailing address

615 HALTON RD
GREENVILLE SC
29607-3403
US

V. Phone/Fax

Practice location:
  • Phone: 864-676-1707
  • Fax: 864-676-9256
Mailing address:
  • Phone: 864-676-1707
  • Fax: 864-676-9256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number11893
License Number StateSC

VIII. Authorized Official

Name: MR. SUTTON LEWIS GRAHAM II
Title or Position: OWNER
Credential: MD
Phone: 864-676-1707