Healthcare Provider Details

I. General information

NPI: 1497159255
Provider Name (Legal Business Name): SURGICAL CENTER OF PONTE VEDRA BEACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 A1A N
PONTE VEDRA BEACH FL
32082-4019
US

IV. Provider business mailing address

1030 A1A N
PONTE VEDRA BEACH FL
32082-4019
US

V. Phone/Fax

Practice location:
  • Phone: 904-285-1199
  • Fax:
Mailing address:
  • Phone: 904-285-1199
  • 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: NANCY K KASTNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-256-0933