Provider Demographics
NPI:1427668342
Name:SPA MEDICAL LLC
Entity type:Organization
Organization Name:SPA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-743-2472
Mailing Address - Street 1:455 PLUM ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3368
Mailing Address - Country:US
Mailing Address - Phone:478-743-2209
Mailing Address - Fax:
Practice Address - Street 1:455 PLUM ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3368
Practice Address - Country:US
Practice Address - Phone:478-743-2209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-05
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty