Healthcare Provider Details

I. General information

NPI: 1215986609
Provider Name (Legal Business Name): SOUTHERN ENDOSCOPY SUITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 OLD NORCROSS RD
LAWRENCEVILLE GA
30045-4317
US

IV. Provider business mailing address

763 OLD NORCROSS RD
LAWRENCEVILLE GA
30045-4317
US

V. Phone/Fax

Practice location:
  • Phone: 678-985-2000
  • Fax: 678-985-1999
Mailing address:
  • Phone: 678-985-2000
  • Fax: 678-985-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number067-200
License Number StateGA

VIII. Authorized Official

Name: MARK B. KUKLER
Title or Position: OWNER
Credential: D.O.,
Phone: 678-985-2000