Provider Demographics
NPI:1467613299
Name:RADIANCE FACIAL COSMETIC SURGERY & LASER CENTER
Entity Type:Organization
Organization Name:RADIANCE FACIAL COSMETIC SURGERY & LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-764-6337
Mailing Address - Street 1:181 ACADEMY ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3178
Mailing Address - Country:US
Mailing Address - Phone:207-764-6337
Mailing Address - Fax:207-764-1446
Practice Address - Street 1:181 ACADEMY ST
Practice Address - Street 2:SUITE #1
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3178
Practice Address - Country:US
Practice Address - Phone:207-764-6337
Practice Address - Fax:207-764-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36809261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME132730000Medicaid
ME132730000Medicaid
MEMM5154Medicare PIN