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General NPI Number Information
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NPI Number | 1942555289
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Entity Type | Organization
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Legal Business Name | ATLANTIC SKIN SURGERY LLC
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Dates
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Enumeration Date | 07/23/2012
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Last Update Date | 07/23/2012
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Provider Practice Location Address
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Address Line | 176 NW MAGNOLIA LAKES BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-3567
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Country | US
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Telephone | 772-828-1907
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Fax |
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Provider Business Mailing Address
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Address Line | 176 NW MAGNOLIA LAKES BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-3567
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Country | US
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Telephone | 772-828-1907
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | RICHARD A JAMES
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Credential | M.D.
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Telephone | 772-828-1907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME66880
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License Number State | FL
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