=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124122577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SURGERY CENTER OF JACKSONVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 06/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10475 CENTURION PKWY N
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-567-6502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13981 PARADISE LN
-----------------------------------------------------
City | DADE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33525-8145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. SANDRA JONES
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 352-567-6502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------