Healthcare Provider Details

I. General information

NPI: 1316179963
Provider Name (Legal Business Name): SHENANDOAH TX ENDOSCOPY ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 VISION PARK BLVD SUITE 160
SHENANDOAH TX
77384-3002
US

IV. Provider business mailing address

20 BURTON HILLS BLVD SUITE 500
NASHVILLE TN
37215-6197
US

V. Phone/Fax

Practice location:
  • Phone: 936-321-8910
  • Fax: 936-321-8913
Mailing address:
  • Phone: 615-240-3720
  • Fax: 615-234-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP A CLENDENIN
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283