1366549511 NPI number — FORT MYERS CHILDREN'S SURGERY CENTER, LLC

Table of content: (NPI 1366549511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366549511 NPI number — FORT MYERS CHILDREN'S SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT MYERS CHILDREN'S 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:
Provider Other Organization Name Type Code:
6
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:
1366549511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9709 LAKESIDE BLVD STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77381-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-489-2198
Provider Business Mailing Address Fax Number:
713-489-2978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 CENTRAL AVE
Provider Second Line Business Practice Location Address:
# 2
Provider Business Practice Location Address City Name:
FT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-275-0665
Provider Business Practice Location Address Fax Number:
239-275-0503
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
DEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-340-1840

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 490000379 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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