Provider Demographics
NPI:1023445079
Name:PURE MED SPA HUNTERSVILLE PLLC
Entity type:Organization
Organization Name:PURE MED SPA HUNTERSVILLE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIGGS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:COOK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-604-2950
Mailing Address - Street 1:10210 HICKORYWOOD HILL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-3332
Mailing Address - Country:US
Mailing Address - Phone:704-450-7563
Mailing Address - Fax:704-288-4202
Practice Address - Street 1:10210 HICKORYWOOD HILL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3332
Practice Address - Country:US
Practice Address - Phone:704-450-7563
Practice Address - Fax:704-288-4202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-07
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001-0037261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG30878Medicare UPIN