1487136412 NPI number — ENDOSCOPY CENTER OF SOUTH SACRAMENTO, LLC

Table of content: (NPI 1487136412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487136412 NPI number — ENDOSCOPY CENTER OF SOUTH SACRAMENTO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENDOSCOPY CENTER OF SOUTH SACRAMENTO, 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:
1487136412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15305 DALLAS PKWY STE 1600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-6491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-763-3893
Provider Business Mailing Address Fax Number:
972-692-6745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8120 TIMBERLAKE WAY STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95823-5413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-681-2350
Provider Business Practice Location Address Fax Number:
916-681-2370
Provider Enumeration Date:
09/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BOON
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL / OFFICER
Authorized Official Telephone Number:
480-567-0259

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)





Copyright © 2007-2025 www.npivalidator.com