=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083618656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELAND SURGERY CENTER LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2005
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 W PLYMOUTH AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-738-6811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 W PLYMOUTH AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-738-6811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. CAROL A CAVANAGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-738-6811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 809
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------