Healthcare Provider Details

I. General information

NPI: 1922054410
Provider Name (Legal Business Name): BRUNSWICK ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 4TH ST
BRUNSWICK GA
31520-3759
US

IV. Provider business mailing address

3217 4TH ST
BRUNSWICK GA
31520-3759
US

V. Phone/Fax

Practice location:
  • Phone: 912-267-1802
  • Fax: 912-267-0061
Mailing address:
  • Phone: 912-267-1802
  • Fax: 912-267-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number063-134
License Number StateGA

VIII. Authorized Official

Name: RITA Y WARREN
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 912-267-1802