Provider Demographics
NPI:1790181436
Name:HEALING WATERS COSMETIC CLINIC, PLLC
Entity Type:Organization
Organization Name:HEALING WATERS COSMETIC CLINIC, PLLC
Other - Org Name:HEALING WATERS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORECKI
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:678-730-7780
Mailing Address - Street 1:33 BUFORD VILLAGE WAY
Mailing Address - Street 2:SUITE 325
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8843
Mailing Address - Country:US
Mailing Address - Phone:678-730-7780
Mailing Address - Fax:
Practice Address - Street 1:6813 FAYETTEVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8721
Practice Address - Country:US
Practice Address - Phone:919-572-1710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty