Provider Demographics
NPI:1366892952
Name:MAINESTATE SURGICAL SERVICES, LLC
Entity type:Organization
Organization Name:MAINESTATE SURGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:ROUZEAU-SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, RNFA
Authorized Official - Phone:678-332-8596
Mailing Address - Street 1:1720 SHIRE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2922
Mailing Address - Country:US
Mailing Address - Phone:678-332-8596
Mailing Address - Fax:
Practice Address - Street 1:1720 SHIRE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-2922
Practice Address - Country:US
Practice Address - Phone:678-332-8596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16052680163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty