Healthcare Provider Details

I. General information

NPI: 1689212151
Provider Name (Legal Business Name): CIVISTA CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 N LA PLATA CT STE 201
LA PLATA MD
20646-5208
US

IV. Provider business mailing address

5 N LA PLATA CT STE 201
LA PLATA MD
20646-5208
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4000
  • Fax:
Mailing address:
  • Phone: 301-609-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALBERT ZANGER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 301-609-5163