Healthcare Provider Details

I. General information

NPI: 1215620877
Provider Name (Legal Business Name): 11TH ST SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 11TH ST
PORTSMOUTH OH
45662-4524
US

IV. Provider business mailing address

1534 11TH ST
PORTSMOUTH OH
45662-4524
US

V. Phone/Fax

Practice location:
  • Phone: 740-355-1161
  • Fax:
Mailing address:
  • Phone: 740-355-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TILLIE ANDRADE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-449-9173