Healthcare Provider Details

I. General information

NPI: 1831810894
Provider Name (Legal Business Name): ORANGE PARK ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 WELLS RD
ORANGE PARK FL
32073-2301
US

IV. Provider business mailing address

14201 DALLAS PKWY
DALLAS TX
75254-2916
US

V. Phone/Fax

Practice location:
  • Phone: 469-872-4706
  • Fax:
Mailing address:
  • Phone: 469-872-4706
  • 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: 469-250-3640