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General NPI Number Information
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NPI Number | 1295885465
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Entity Type | Organization
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Legal Business Name | PLASTIC SURGERY CENTER OF THE SOUTH
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 120 VANN ST NE SUITE 150
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City | MARIETTA
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State | GA
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Zip | 30060-7250
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Country | US
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Telephone | 772-421-1242
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Fax | 770-424-6652
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Provider Business Mailing Address
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Address Line | 120 VANN ST NE SUITE 150
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City | MARIETTA
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State | GA
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Zip | 30060-7250
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Country | US
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Telephone | 772-421-1242
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Fax | 770-424-6652
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JAMES EDGAR LEAKE
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Credential | M.D.
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Telephone | 770-421-1242
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 261QA1903X
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License Number State | GA
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