Provider Demographics
NPI:1073093175
Name:VIVIFY PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:VIVIFY PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:833-284-8439
Mailing Address - Street 1:1000 W KENNEDY BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1940
Mailing Address - Country:US
Mailing Address - Phone:406-848-4391
Mailing Address - Fax:509-323-1607
Practice Address - Street 1:1000 W KENNEDY BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2494
Practice Address - Country:US
Practice Address - Phone:406-848-4391
Practice Address - Fax:509-323-1607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1341992086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty