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General NPI Number Information
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NPI Number | 1053404574
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Entity Type | Organization
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Legal Business Name | KINGSPORT AMBULATORY SURGERY CTR
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 01/14/2020
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Provider Practice Location Address
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Address Line | 2204 PAVILION DRIVE SUITE 300
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City | KINGSPORT
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State | TN
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Zip | 37660-4653
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Country | US
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Telephone | 423-857-6300
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Fax | 423-857-6324
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Provider Business Mailing Address
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Address Line | 14201 DALLAS PKWY
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City | DALLAS
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State | TX
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Zip | 75254-2916
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Country | US
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Telephone | 972-763-3859
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Fax | 972-920-3445
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Authorized Official
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Title or Position | OFFICER/AUTHORIZED OFFICIAL
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Name | JENETHA D MORAN
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Credential |
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Telephone | 972-763-3893
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 0000000113
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License Number State | TN
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