=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548192339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIALTY SURGICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2026
-----------------------------------------------------
Last Update Date | 06/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11414 LAKE SHERWOOD AVE N STE B
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70816-0406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-532-4058
-----------------------------------------------------
Fax | 225-659-8031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11414 LAKE SHERWOOD AVE N STE B
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70816-0406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-532-4058
-----------------------------------------------------
Fax | 225-659-8031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHARLES W MOCK
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 225-532-4058
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------