=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194708024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGVIEW PHYSICIANS SURGICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 N 4TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-4756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-248-9240
-----------------------------------------------------
Fax | 903-248-9244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 N 4TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-4756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-248-9240
-----------------------------------------------------
Fax | 903-248-9244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. JACINDA MICHEAL BENTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-248-9240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 8064
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------