Provider Demographics
NPI:1083892475
Name:SOQUE SURGICAL, LLC
Entity Type:Organization
Organization Name:SOQUE SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-754-8339
Mailing Address - Street 1:PO BOX 1660
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-0028
Mailing Address - Country:US
Mailing Address - Phone:706-754-8339
Mailing Address - Fax:706-754-8460
Practice Address - Street 1:855 AUSTIN DRIVE
Practice Address - Street 2:
Practice Address - City:DOMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-754-8339
Practice Address - Fax:706-754-8460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6242Medicare PIN
GAG49843Medicare UPIN