Provider Demographics
NPI:1447458591
Name:ADVANCED PLASTIC SURGERY CENTER, L.L.C.
Entity type:Organization
Organization Name:ADVANCED PLASTIC SURGERY CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:FETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-777-0200
Mailing Address - Street 1:1615 PETROGLYPH POINT DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6539
Mailing Address - Country:US
Mailing Address - Phone:928-777-0200
Mailing Address - Fax:928-443-1117
Practice Address - Street 1:1615 PETROGLYPH POINT DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6539
Practice Address - Country:US
Practice Address - Phone:928-777-0200
Practice Address - Fax:928-443-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical