Provider Demographics
NPI:1053598409
Name:NEW IMAGE COSMETIC SURGERY CENTER, INC.
Entity type:Organization
Organization Name:NEW IMAGE COSMETIC SURGERY CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-424-8882
Mailing Address - Street 1:10167 W SUNRISE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-7619
Mailing Address - Country:US
Mailing Address - Phone:954-424-8882
Mailing Address - Fax:954-424-8858
Practice Address - Street 1:10167 W SUNRISE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-7619
Practice Address - Country:US
Practice Address - Phone:954-424-8882
Practice Address - Fax:954-424-8858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical