Healthcare Provider Details

I. General information

NPI: 1487280608
Provider Name (Legal Business Name): LAKESHORE SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 LAKE WOODLANDS DR STE 175
SPRING TX
77382-2565
US

IV. Provider business mailing address

6701 LAKE WOODLANDS DR STE 175
SPRING TX
77382-2565
US

V. Phone/Fax

Practice location:
  • Phone: 281-825-4607
  • Fax:
Mailing address:
  • Phone: 281-825-4607
  • Fax:

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. VIM X HEAD
Title or Position: CEO
Credential:
Phone: 281-825-4607