Healthcare Provider Details

I. General information

NPI: 1124036843
Provider Name (Legal Business Name): COSMETIC SURGERY CENTER FOR WOMEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 SOUTH WITCHDUCK RD SUITE 100
VIRGINIA BEACH VA
23462
US

IV. Provider business mailing address

396 SOUTH WITCHDUCK RD SUITE 100
VIRGINIA BEACH VA
23462
US

V. Phone/Fax

Practice location:
  • Phone: 757-497-5400
  • Fax: 757-497-8811
Mailing address:
  • Phone: 757-497-5400
  • Fax: 757-497-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101051490
License Number StateVA

VIII. Authorized Official

Name: JOANN LOPES
Title or Position: PRESIDENT
Credential: MD
Phone: 757-497-5400