Provider Demographics
NPI:1255700092
Name:SPECIFIED SOLUTIONS SURGICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:SPECIFIED SOLUTIONS SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERROD
Authorized Official - Middle Name:LAQUINTON
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:SR
Authorized Official - Credentials:CEO
Authorized Official - Phone:404-932-0295
Mailing Address - Street 1:863 FLAT SHOALS RD SE
Mailing Address - Street 2:STE C #250
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6633
Mailing Address - Country:US
Mailing Address - Phone:404-932-0295
Mailing Address - Fax:
Practice Address - Street 1:863 FLAT SHOALS RD SE
Practice Address - Street 2:STE C #250
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6633
Practice Address - Country:US
Practice Address - Phone:404-932-0295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2610163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty