Provider Demographics
NPI:1285936641
Name:RIVERS EDGE AESTHETIC SURGERY, LLC
Entity type:Organization
Organization Name:RIVERS EDGE AESTHETIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMOOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-335-3349
Mailing Address - Street 1:4201 SOUTH MINNESOTA AVENUE
Mailing Address - Street 2:STE. 111
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6742
Mailing Address - Country:US
Mailing Address - Phone:605-335-3349
Mailing Address - Fax:605-336-8436
Practice Address - Street 1:4201 SOUTH MINNESOTA AVENUE
Practice Address - Street 2:STE. 111
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6742
Practice Address - Country:US
Practice Address - Phone:605-335-3349
Practice Address - Fax:605-336-8436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical