Provider Demographics
NPI:1073112777
Name:IDEAL IMAGE PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:IDEAL IMAGE PLASTIC SURGERY, LLC
Other - Org Name:RCH PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-746-8779
Mailing Address - Street 1:4128 DOOLITTLE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4117
Mailing Address - Country:US
Mailing Address - Phone:913-608-4586
Mailing Address - Fax:270-216-6827
Practice Address - Street 1:8040 PARALLEL PKWY STE 112A
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2072
Practice Address - Country:US
Practice Address - Phone:913-608-4586
Practice Address - Fax:270-216-6827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty