1619979580 NPI number — PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619979580 NPI number — PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVENTHEALTH SURGERY CENTER PORT ORANGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619979580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1185 DUNLAWTON AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32127-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-777-7151
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1185 DUNLAWTON AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-672-0017
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PETERS
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
ALICE
Authorized Official Title or Position:
ASC ADMINISTRATOR, NURSING DIRECTOR
Authorized Official Telephone Number:
386-777-7151

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1227 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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