Provider Demographics
NPI:1639416365
Name:FAYETTE PLASTICSURGERY CENTER LLC
Entity Type:Organization
Organization Name:FAYETTE PLASTICSURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:RANIERE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-461-4000
Mailing Address - Street 1:874 LANIER AVE W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7662
Mailing Address - Country:US
Mailing Address - Phone:770-461-4000
Mailing Address - Fax:770-603-7040
Practice Address - Street 1:874 LANIER AVE W
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7662
Practice Address - Country:US
Practice Address - Phone:770-461-4000
Practice Address - Fax:770-603-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12056659261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical