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General NPI Number Information
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NPI Number | 1174906648
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Entity Type | Organization
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Legal Business Name | AESTHETIC CENTER FOR BREAST AND COSMETIC SURGERY, PA
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Dates
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Enumeration Date | 07/02/2015
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Last Update Date | 07/02/2015
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Provider Practice Location Address
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Address Line | 615 HALTON RD
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City | GREENVILLE
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State | SC
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Zip | 29607-3403
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Country | US
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Telephone | 864-676-1707
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Fax | 864-676-9256
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Provider Business Mailing Address
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Address Line | 615 HALTON RD
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City | GREENVILLE
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State | SC
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Zip | 29607-3403
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Country | US
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Telephone | 864-676-1707
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Fax | 864-676-9256
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Authorized Official
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Title or Position | OWNER
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Name | MR. SUTTON LEWIS GRAHAM II
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Credential | MD
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Telephone | 864-676-1707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 11893
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License Number State | SC
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