Healthcare Provider Details

I. General information

NPI: 1598643140
Provider Name (Legal Business Name): ST. AUGUSTINE AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GROOVER LOOP
ST AUGUSTINE FL
32086-6548
US

IV. Provider business mailing address

45 GROOVER LOOP
ST. AUGUSTINE FL
32086-6548
US

V. Phone/Fax

Practice location:
  • Phone: 904-648-8660
  • Fax:
Mailing address:
  • Phone: 904-648-8660
  • 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: ROBERT HAEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 904-648-8660