Healthcare Provider Details

I. General information

NPI: 1962466847
Provider Name (Legal Business Name): GULF COAST ENDOSCOPY CENTER OF VENICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 E VENICE AVE
VENICE FL
34285-7151
US

IV. Provider business mailing address

1220 E VENICE AVE
VENICE FL
34285-7151
US

V. Phone/Fax

Practice location:
  • Phone: 941-484-5000
  • Fax: 941-484-4414
Mailing address:
  • Phone: 636-938-6868
  • Fax: 636-938-1487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1117
License Number StateFL

VIII. Authorized Official

Name: MS. TERRI LOPEZ
Title or Position: ADMINISTRATOR
Credential: CASC
Phone: 941-484-5000