Healthcare Provider Details

I. General information

NPI: 1033624663
Provider Name (Legal Business Name): TEXAS CENTER FOR FACIAL PLASTIC & LASER SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14603 HUEBNER RD STE 102
SAN ANTONIO TX
78230-5469
US

IV. Provider business mailing address

14603 HUEBNER RD STE 102
SAN ANTONIO TX
78230-5469
US

V. Phone/Fax

Practice location:
  • Phone: 210-468-5426
  • Fax: 210-468-3282
Mailing address:
  • Phone: 210-468-5426
  • Fax: 210-468-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: MS. KELLIE HAWKINS
Title or Position: CREDENTIALING ACCOUNT MANAGER
Credential:
Phone: 210-298-6847