Healthcare Provider Details

I. General information

NPI: 1720072457
Provider Name (Legal Business Name): CENTRAL TEXAS AMBULATORY ENDOSCOPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WONDER WORLD DR SUITE 105
SAN MARCOS TX
78666-7546
US

IV. Provider business mailing address

1305 WONDER WORLD DR SUITE 105
SAN MARCOS TX
78666-7546
US

V. Phone/Fax

Practice location:
  • Phone: 512-754-8676
  • Fax: 512-754-8680
Mailing address:
  • Phone: 512-754-8676
  • Fax: 512-754-8680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number000385
License Number StateTX

VIII. Authorized Official

Name: MRS. BONNIE LYNN ANDERS
Title or Position: ADMINISTRATIVE ASST.
Credential:
Phone: 512-754-8676