Healthcare Provider Details

I. General information

NPI: 1750569869
Provider Name (Legal Business Name): WACO LITHOTRIPSY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 BROADWAY ST BOX 189
SAN ANTONIO TX
78209-5710
US

IV. Provider business mailing address

6339 E SPEEDWAY BLVD SUITE 201
TUCSON AZ
85710-1147
US

V. Phone/Fax

Practice location:
  • Phone: 520-323-8732
  • Fax: 520-547-1865
Mailing address:
  • Phone: 520-323-8732
  • Fax: 520-547-1865

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: LACEY DINH
Title or Position: REVENUE CYCLE MANAGER OF ABS
Credential:
Phone: 520-258-0326