=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467812693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENINSULA SURGERY AND AESTHETICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2016
-----------------------------------------------------
Last Update Date | 03/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 E FAIRVIEW AVE
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-299-0737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1862
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-1862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-299-0737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUZANNE RENEE SINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-299-0737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0800X
-----------------------------------------------------
Taxonomy Name | Endoscopy Clinic/Center
-----------------------------------------------------
License Number | 2272
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------