Provider Demographics
NPI:1801231659
Name:NORDBERG PLASTIC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NORDBERG PLASTIC SURGERY CENTER, LLC
Other - Org Name:IMAGINE AESTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIF
Authorized Official - Middle Name:O
Authorized Official - Last Name:NORDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-324-4700
Mailing Address - Street 1:2001 W MAIN ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4501
Mailing Address - Country:US
Mailing Address - Phone:203-324-4700
Mailing Address - Fax:203-324-5691
Practice Address - Street 1:2001 W MAIN ST
Practice Address - Street 2:SUITE 150
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-324-4700
Practice Address - Fax:203-324-5691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center