Healthcare Provider Details

I. General information

NPI: 1790174274
Provider Name (Legal Business Name): PARKSIDE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 S LOOP 336 W SUITE 130
CONROE TX
77304-3319
US

IV. Provider business mailing address

690 S LOOP 336 W SUITE 130
CONROE TX
77304-3319
US

V. Phone/Fax

Practice location:
  • Phone: 936-760-7660
  • Fax: 936-760-7661
Mailing address:
  • Phone: 936-760-7660
  • Fax: 936-760-7661

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: NELSON ATEMBE TAJONG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 936-760-7660