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General NPI Number Information
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NPI Number | 1316121429
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Entity Type | Organization
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Legal Business Name | PLASTIC SURGERY OPERATIVE SUITE, LLC
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Dates
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Enumeration Date | 12/26/2007
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Last Update Date | 05/05/2015
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Provider Practice Location Address
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Address Line | 230 NORTHSIDE DR
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City | VALDOSTA
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State | GA
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Zip | 31602-1858
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Country | US
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Telephone | 229-242-3002
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Fax |
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Provider Business Mailing Address
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Address Line | 230 NORTHSIDE DR
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City | VALDOSTA
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State | GA
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Zip | 31602-1858
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MANDY PARKS
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Credential |
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Telephone | 229-242-3002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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