=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841361052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AESTHETIC LASER & SURGERY FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-228-7200
-----------------------------------------------------
Fax | 229-228-5193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-228-7200
-----------------------------------------------------
Fax | 229-228-5193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. G. COURTNEY HOUSTON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 229-228-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 136-113
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------