Provider Demographics
NPI:1336912021
Name:AVENUE AESTHETIC AND RECONSTRUCTIVE SURGERY LLC
Entity type:Organization
Organization Name:AVENUE AESTHETIC AND RECONSTRUCTIVE SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAVANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-363-0256
Mailing Address - Street 1:489 N MILLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-3807
Mailing Address - Country:US
Mailing Address - Phone:706-363-0256
Mailing Address - Fax:706-622-4360
Practice Address - Street 1:489 N MILLEDGE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-3807
Practice Address - Country:US
Practice Address - Phone:706-363-0256
Practice Address - Fax:706-622-4360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty