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General NPI Number Information
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NPI Number | 1821397654
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Entity Type | Organization
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Legal Business Name | RENUE SURGERY CENTER OF WAYCROSS, LLC
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Dates
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Enumeration Date | 03/18/2011
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Last Update Date | 10/28/2020
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Provider Practice Location Address
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Address Line | 1905 TEBEAU ST
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City | WAYCROSS
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State | GA
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Zip | 31501-6356
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Country | US
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Telephone | 912-280-9977
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Fax | 912-280-9995
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Provider Business Mailing Address
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Address Line | PO BOX 2198
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City | BRUNSWICK
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State | GA
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Zip | 31521-2198
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Country | US
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Telephone | 912-280-9977
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Fax | 912-280-9995
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Authorized Official
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Title or Position | MANAGER
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Name | DR. CHARLES WILLIAM MITCHELL
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Credential | M.D.
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Telephone | 912-280-9977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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