Provider Demographics
NPI:1417402942
Name:SCULPTRX INC
Entity Type:Organization
Organization Name:SCULPTRX INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSAUNDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-613-2971
Mailing Address - Street 1:125 TOWNPARK DR NW
Mailing Address - Street 2:STE 300
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5803
Mailing Address - Country:US
Mailing Address - Phone:770-450-0846
Mailing Address - Fax:
Practice Address - Street 1:125 TOWNPARK DR NW
Practice Address - Street 2:STE 300
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5803
Practice Address - Country:US
Practice Address - Phone:770-450-0846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34119207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty