Healthcare Provider Details

I. General information

NPI: 1235509993
Provider Name (Legal Business Name): PEDIATRIC AMBULATORY SURGERY CENTER SOUTHLAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 E STATE HIGHWAY 114
SOUTHLAKE TX
76092-4406
US

IV. Provider business mailing address

470 E STATE HIGHWAY 114
SOUTHLAKE TX
76092-4406
US

V. Phone/Fax

Practice location:
  • Phone: 817-730-5437
  • Fax: 817-724-0010
Mailing address:
  • Phone: 817-730-5437
  • Fax: 817-724-0010

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: MR. JERRY LEE
Title or Position: VICE PRESIDENT OF ACCOUNTING
Credential:
Phone: 214-456-0588