=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093306144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATY SURGICAL ASSIST SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2021
-----------------------------------------------------
Last Update Date | 02/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 NEW HOPE LN
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-0285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-536-5726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 NEW HOPE LN
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-0285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-536-5726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | MR. EMMANUEL A. ALCOSEBA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-536-5726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------