Healthcare Provider Details

I. General information

NPI: 1871557652
Provider Name (Legal Business Name): PORT ST LUCIE SURGERY CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 SE WEST STAR AVE
PORT ST LUCIE FL
34952-7557
US

IV. Provider business mailing address

1310 SE WEST STAR AVE
PORT ST LUCIE FL
34952-7557
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-5200
  • Fax: 772-337-7955
Mailing address:
  • Phone: 772-337-5200
  • Fax: 772-337-7955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1040
License Number StateFL

VIII. Authorized Official

Name: WILLIAM GREGORY SWINNEY
Title or Position: VP
Credential:
Phone: 972-789-2877