Provider Demographics
NPI:1861653685
Name:AESTHETIC SURGERY CENTER OF WINTER PARK, LLC
Entity Type:Organization
Organization Name:AESTHETIC SURGERY CENTER OF WINTER PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARTOG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:321-282-0561
Mailing Address - Street 1:4355 BEAR GULLY RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-9422
Mailing Address - Country:US
Mailing Address - Phone:321-282-0561
Mailing Address - Fax:321-282-0565
Practice Address - Street 1:4355 BEAR GULLY RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-9422
Practice Address - Country:US
Practice Address - Phone:321-282-0561
Practice Address - Fax:321-282-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1199261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical