Provider Demographics
NPI:1558008599
Name:SUNRISE INTRACOASTAL PLASTIC SURGERY CENTER PA
Entity Type:Organization
Organization Name:SUNRISE INTRACOASTAL PLASTIC SURGERY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:549-147-5499
Mailing Address - Street 1:910 NE 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3607
Mailing Address - Country:US
Mailing Address - Phone:954-533-8029
Mailing Address - Fax:
Practice Address - Street 1:910 NE 26TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3607
Practice Address - Country:US
Practice Address - Phone:954-533-8029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOSR105OtherSTATE LICENSE