Healthcare Provider Details

I. General information

NPI: 1710152194
Provider Name (Legal Business Name): EXQUISITE SURGERY ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 PINEY POINT
HOUSTON TX
77024
US

IV. Provider business mailing address

306 CYPRESS VISTA
HOUSTON TX
77094
US

V. Phone/Fax

Practice location:
  • Phone: 713-465-4106
  • Fax: 713-465-7334
Mailing address:
  • Phone: 713-465-4106
  • Fax: 713-465-7334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MARSHA K DIMITROFF
Title or Position: OWNER
Credential:
Phone: 713-465-4106