Provider Demographics
NPI:1942555289
Name:ATLANTIC SKIN SURGERY LLC
Entity Type:Organization
Organization Name:ATLANTIC SKIN SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-828-1907
Mailing Address - Street 1:176 NW MAGNOLIA LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3567
Mailing Address - Country:US
Mailing Address - Phone:772-828-1907
Mailing Address - Fax:
Practice Address - Street 1:176 NW MAGNOLIA LAKES BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3567
Practice Address - Country:US
Practice Address - Phone:772-828-1907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66880208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty