Provider Demographics
NPI:1265871719
Name:PINNACLE PLASTIC SURGERY ASSOCIATES LLC
Entity type:Organization
Organization Name:PINNACLE PLASTIC SURGERY ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KLENKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-815-6699
Mailing Address - Street 1:7 MALLETT WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6064
Mailing Address - Country:US
Mailing Address - Phone:843-815-6699
Mailing Address - Fax:843-815-6695
Practice Address - Street 1:7 MALLETT WAY
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6064
Practice Address - Country:US
Practice Address - Phone:843-815-6699
Practice Address - Fax:843-815-6695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC355635Medicaid
SCC732Medicare UPIN