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General NPI Number Information
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NPI Number | 1164662912
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Entity Type | Organization
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Legal Business Name | SPACE COAST SURGERY CENTER LLC
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Dates
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Enumeration Date | 03/05/2009
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Last Update Date | 11/01/2022
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Provider Practice Location Address
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Address Line | 595 N COURTENAY PKWY 103
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4851
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Country | US
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Telephone | 813-569-6500
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Fax |
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Provider Business Mailing Address
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Address Line | 595 N COURTENAY PKWY STE 103
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4852
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Country | US
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Telephone | 813-890-1800
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Fax |
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Authorized Official
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Title or Position | OFFICER AND AUTHORIZED OFFICIAL
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Name | JENNIFER B BALDOCK
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Credential |
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Telephone | 615-234-5954
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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 |
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License Number State |
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