=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205809795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAKHURST ENDOSCOPY ASC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2006
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1907 HIGHWAY 35 SUITE 9
-----------------------------------------------------
City | OAKHURST
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07755-2765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-517-8885
-----------------------------------------------------
Fax | 732-517-0304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1A BURTON HILLS BLVD ATTN: L&C
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37215-6103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-517-8885
-----------------------------------------------------
Fax | 732-517-0304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MANAGER OF LLC
-----------------------------------------------------
Name | MS. PHILLIP CLENDENIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-665-1283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | NONE REQUIRED
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------