Healthcare Provider Details

I. General information

NPI: 1225701824
Provider Name (Legal Business Name): EAST WEST LASER AND AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 EAST-WEST PARKWAY SUITE 1
FLEMING ISLAND FL
32003
US

IV. Provider business mailing address

1855 EAST-WEST PARKWAY SUITE 1
FLEMING ISLAND FL
32003
US

V. Phone/Fax

Practice location:
  • Phone: 561-630-6277
  • Fax: 561-630-6062
Mailing address:
  • Phone: 561-630-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL A. PECORARO
Title or Position: MANAGER
Credential: M.D.
Phone: 904-272-2020