Healthcare Provider Details

I. General information

NPI: 1477595056
Provider Name (Legal Business Name): KISSIMMEE ENDOSCOPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 OAK COMMONS BLVD
KISSIMMEE FL
34741-4213
US

IV. Provider business mailing address

715 OAK COMMONS BLVD
KISSIMMEE FL
34741-4213
US

V. Phone/Fax

Practice location:
  • Phone: 407-931-2816
  • Fax: 407-931-3485
Mailing address:
  • Phone: 407-931-2816
  • Fax: 407-931-3485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number1130
License Number StateFL

VIII. Authorized Official

Name: MR. CHRISTOPHER A HOLDEN
Title or Position: CHIEF MANGER OF LLC
Credential:
Phone: 615-665-1283