1053598409 NPI number — NEW IMAGE COSMETIC SURGERY CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053598409 NPI number — NEW IMAGE COSMETIC SURGERY CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW IMAGE COSMETIC SURGERY CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053598409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10167 W SUNRISE BLVD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33322-7619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-424-8882
Provider Business Mailing Address Fax Number:
954-424-8858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10167 W SUNRISE BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
PLANTATION
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33322-7619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-424-8882
Provider Business Practice Location Address Fax Number:
954-424-8858
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSON
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
954-424-8882

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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