=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639360258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACHES FACIAL AND NASAL SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2007
-----------------------------------------------------
Last Update Date | 02/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1361 13TH AVE S STE 125
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-3260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-249-2580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1361 13TH AVE S STE 125
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-3260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-249-2580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SCOTT J TRIMAS
-----------------------------------------------------
Credential | MDFACS
-----------------------------------------------------
Telephone | 904-249-2580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------