Provider Demographics
NPI:1770631392
Name:PREMIERE PLASTIC COSMETIC AND LASER SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PREMIERE PLASTIC COSMETIC AND LASER SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PERCY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-294-9255
Mailing Address - Street 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1264
Mailing Address - Country:US
Mailing Address - Phone:937-294-9255
Mailing Address - Fax:937-294-9256
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:SUITE 4400
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:937-294-9255
Practice Address - Fax:937-294-9256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH037634261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3035227Medicaid
OH3612351Medicare PIN