Provider Demographics
NPI:1447541230
Name:MEDICAL AESTHETIC CENTER LLC
Entity type:Organization
Organization Name:MEDICAL AESTHETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CAL
Authorized Official - Last Name:PINELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-638-7799
Mailing Address - Street 1:60 CINEMA LANE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-6631
Mailing Address - Country:US
Mailing Address - Phone:912-638-7799
Mailing Address - Fax:912-638-7755
Practice Address - Street 1:60 CINEMA LANE
Practice Address - Street 2:SUITE 140
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-6631
Practice Address - Country:US
Practice Address - Phone:912-638-7799
Practice Address - Fax:912-638-7755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL AESTETIC & WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-27
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058102207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty