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General NPI Number Information
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NPI Number | 1518472299
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Entity Type | Organization
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Legal Business Name | PROSOURCE SURGICAL ASSISTING, LLC
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Dates
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Enumeration Date | 12/04/2017
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Last Update Date | 07/31/2023
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Provider Practice Location Address
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Address Line | 2414 CALIBRE CREEK PKWY
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City | ROSWELL
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State | GA
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Zip | 30076-4540
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Country | US
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Telephone | 912-604-0905
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Fax | 770-558-4499
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Provider Business Mailing Address
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Address Line | PO BOX 768873
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City | ROSWELL
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State | GA
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Zip | 30076-8211
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Country | US
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Telephone | 912-604-0905
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Fax | 678-243-5735
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Authorized Official
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Title or Position | CERTIFIED SURGICAL ASSISTANT
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Name | MARCELLA ANN TOWNSEND
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Credential | CSA
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Telephone | 912-604-0905
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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