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General NPI Number Information
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NPI Number | 1215204268
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Entity Type | Organization
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Legal Business Name | PROVINCIAL PARK SURGERY CENTER, LLC
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Dates
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Enumeration Date | 11/18/2011
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Last Update Date | 11/18/2011
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Provider Practice Location Address
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Address Line | 21300 PROVINCIAL BLVD SUITE 200
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City | KATY
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State | TX
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Zip | 77450-7580
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Country | US
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Telephone | 713-554-7500
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Fax | 713-554-6656
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Provider Business Mailing Address
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Address Line | 21300 PROVINCIAL BLVD SUITE 200
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City | KATY
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State | TX
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Zip | 77450-7580
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Country | US
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Telephone | 713-554-7500
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Fax | 713-554-6656
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Authorized Official
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Title or Position | CHAIRMAN OF THE BOARD
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Name | MENNEN T. GALLAS
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Credential | MD
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Telephone | 281-646-1114
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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 | TX
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