Healthcare Provider Details

I. General information

NPI: 1033734785
Provider Name (Legal Business Name): CARDIOVASCULAR INSTITUTE OF THE SOUTH ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 INNOVATION COURT
GRAY LA
70359
US

IV. Provider business mailing address

PO BOX 4176
HOUMA LA
70361-4176
US

V. Phone/Fax

Practice location:
  • Phone: 985-876-0300
  • Fax:
Mailing address:
  • Phone: 985-876-0300
  • 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: MR. DAVID C KONUR
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 985-876-0300