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General NPI Number Information
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NPI Number | 1386855096
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Entity Type | Organization
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Legal Business Name | INSTITUTE OF FACIAL SURGERY INC
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 08/24/2010
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Provider Practice Location Address
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Address Line | 1093 S WICKHAM RD
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City | WEST MELBOURNE
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State | FL
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Zip | 32904-1652
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Country | US
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Telephone | 321-674-3900
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Fax | 321-722-3303
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Provider Business Mailing Address
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Address Line | 1093 S WICKHAM RD
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City | WEST MELBOURNE
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State | FL
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Zip | 32904-1652
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Country | US
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Telephone | 321-674-3900
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Fax | 321-722-3303
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Authorized Official
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Title or Position | OWNERDOCTOR
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Name | DR. LANCE F GRENEVICKI
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Credential | DDS,MD,FACS
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Telephone | 321-674-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 429
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License Number State | FL
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