1790181436 NPI number — HEALING WATERS COSMETIC CLINIC, PLLC

Table of content: (NPI 1790181436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790181436 NPI number — HEALING WATERS COSMETIC CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALING WATERS COSMETIC CLINIC, PLLC
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:
1790181436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 BUFORD VILLAGE WAY
Provider Second Line Business Mailing Address:
SUITE 325
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-8843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-730-7780
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6813 FAYETTEVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27713-8721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-572-1710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GORECKI
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
678-730-7780

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com