Provider Demographics
NPI:1033624663
Name:TEXAS CENTER FOR FACIAL PLASTIC & LASER SURGERY, LLC
Entity Type:Organization
Organization Name:TEXAS CENTER FOR FACIAL PLASTIC & LASER SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ACCOUNT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-298-6847
Mailing Address - Street 1:14603 HUEBNER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5469
Mailing Address - Country:US
Mailing Address - Phone:210-468-5426
Mailing Address - Fax:210-468-3282
Practice Address - Street 1:14603 HUEBNER RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5469
Practice Address - Country:US
Practice Address - Phone:210-468-5426
Practice Address - Fax:210-468-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty