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General NPI Number Information
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NPI Number | 1659139590
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Entity Type | Organization
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Legal Business Name | MAGNOLIA LANE PLASTIC SURGERY, LLC
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Dates
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Enumeration Date | 03/06/2024
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 3633 WHEELER RD STE 110
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City | AUGUSTA
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State | GA
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Zip | 30909-6544
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Country | US
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Telephone | 706-723-1632
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Fax | 706-869-3841
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Provider Business Mailing Address
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Address Line | 607 RONALD REAGAN DR UNIT 724
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City | EVANS
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State | GA
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Zip | 30809-7729
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. TAYLOR CATO
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Credential |
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Telephone | 706-723-1632
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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