Provider Demographics
NPI:1346266087
Name:FSLJC, LLC.
Entity Type:Organization
Organization Name:FSLJC, LLC.
Other - Org Name:THE RENAISSANCE CENTER FOR PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLINI
Authorized Official - Suffix:
Authorized Official - Credentials:RT (R) RDMS RDCS
Authorized Official - Phone:570-674-6525
Mailing Address - Street 1:1845 MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-1482
Mailing Address - Country:US
Mailing Address - Phone:570-674-6525
Mailing Address - Fax:570-674-6520
Practice Address - Street 1:1845 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708-1482
Practice Address - Country:US
Practice Address - Phone:570-674-6525
Practice Address - Fax:570-674-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101652Medicare PIN
PA39C0001208Medicare ID - Type Unspecified