Healthcare Provider Details

I. General information

NPI: 1821342858
Provider Name (Legal Business Name): SURGCENTER OF ORANGE PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 WELLS RD FL 1
ORANGE PARK FL
32073-2301
US

IV. Provider business mailing address

805 WELLS RD FL 1
ORANGE PARK FL
32073-2301
US

V. Phone/Fax

Practice location:
  • Phone: 904-643-3326
  • Fax: 904-592-9726
Mailing address:
  • Phone: 904-643-3326
  • 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: COLLIN LEMAISTRE
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 214-213-0723