Provider Demographics
NPI:1659139590
Name:MAGNOLIA LANE PLASTIC SURGERY, LLC
Entity type:Organization
Organization Name:MAGNOLIA LANE PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-723-1632
Mailing Address - Street 1:607 RONALD REAGAN DR UNIT 724
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3633 WHEELER RD STE 110
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6544
Practice Address - Country:US
Practice Address - Phone:706-723-1632
Practice Address - Fax:706-869-3841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty