Provider Demographics
NPI:1467620161
Name:SOUTHEASTERN FACIAL PLASTIC COSMETIC SURGERY CENTER, P.A.
Entity Type:Organization
Organization Name:SOUTHEASTERN FACIAL PLASTIC COSMETIC SURGERY CENTER, P.A.
Other - Org Name:SOUTHEASTERN PLASTIC SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-722-5904
Mailing Address - Street 1:247 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1306
Mailing Address - Country:US
Mailing Address - Phone:843-722-5904
Mailing Address - Fax:843-722-1564
Practice Address - Street 1:247 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1306
Practice Address - Country:US
Practice Address - Phone:843-722-5904
Practice Address - Fax:843-722-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical