Snake River Plastic Surgery LLC
Specialist in Jackson, WY. Organization (NPI-2).
NPI number1104137074
StatusActive
Last updated in NPPESJun 25, 2010
Details
- NPI
- 1104137074
- Entity type
- Organization (NPI-2)
- Legal business name
- Snake River Plastic Surgery LLC
- Organization subpart
- No
- Enumeration date
- Jun 25, 2010
- Last updated
- Jun 25, 2010
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 174400000X | Specialist | 2735A | WY | Yes |
Practice location
555 E. BroadwaySuite 212
Jackson, WY 83001
Phone 307-733-6077
Mailing address
Po Box 2862Jackson, WY 83001-2862
Phone 307-733-6077
Authorized official
Michael Barry Gellis
Member
3077336077
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