Healthcare Provider Details

I. General information

NPI: 1598905317
Provider Name (Legal Business Name): ISLAND ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 MONTAUK HWY
WEST ISLIP NY
11795-4939
US

IV. Provider business mailing address

1175 MONTAUK HWY SUITE 1
WEST ISLIP NY
11795-4939
US

V. Phone/Fax

Practice location:
  • Phone: 631-482-1652
  • Fax: 631-482-1656
Mailing address:
  • Phone: 631-482-1652
  • Fax: 631-482-1656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. NORA VIOLA
Title or Position: ADMINISTRATOR
Credential:
Phone: 631-482-1652