Healthcare Provider Details

I. General information

NPI: 1609940899
Provider Name (Legal Business Name): 2096 EAST OCEAN BOULEVARD, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2096 SE OCEAN BLVD
STUART FL
34996-3304
US

IV. Provider business mailing address

2096 SE OCEAN BLVD
STUART FL
34996-3304
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-0174
  • Fax: 772-223-0558
Mailing address:
  • Phone: 772-223-0174
  • Fax: 772-223-0558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number901
License Number StateFL

VIII. Authorized Official

Name: MS. BARBARA ANN TIDWELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 772-223-0174