Provider Demographics
NPI:1386855096
Name:INSTITUTE OF FACIAL SURGERY INC
Entity Type:Organization
Organization Name:INSTITUTE OF FACIAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERDOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:F
Authorized Official - Last Name:GRENEVICKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MD,FACS
Authorized Official - Phone:321-674-3900
Mailing Address - Street 1:1093 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1652
Mailing Address - Country:US
Mailing Address - Phone:321-674-3900
Mailing Address - Fax:321-722-3303
Practice Address - Street 1:1093 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1652
Practice Address - Country:US
Practice Address - Phone:321-674-3900
Practice Address - Fax:321-722-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3129Medicare ID - Type Unspecified