Provider Demographics
NPI:1700929874
Name:THE PLASTIC SURGERY CENTER LLP
Entity Type:Organization
Organization Name:THE PLASTIC SURGERY CENTER LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-1629
Mailing Address - Street 1:385 BERT KOUNS IND. LOOP, BLDG 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8124
Mailing Address - Country:US
Mailing Address - Phone:318-221-1629
Mailing Address - Fax:
Practice Address - Street 1:385 BERT KOUNS IND. LOOP, BLDG 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8124
Practice Address - Country:US
Practice Address - Phone:318-221-1629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CT13Medicare PIN