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General NPI Number Information
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NPI Number | 1215620877
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Entity Type | Organization
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Legal Business Name | 11TH ST SURGICAL LLC
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Dates
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Enumeration Date | 05/31/2023
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Last Update Date | 04/24/2024
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Provider Practice Location Address
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Address Line | 1534 11TH ST
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City | PORTSMOUTH
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State | OH
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Zip | 45662-4524
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Country | US
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Telephone | 740-355-1161
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Fax |
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Provider Business Mailing Address
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Address Line | 1534 11TH ST
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City | PORTSMOUTH
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State | OH
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Zip | 45662-4524
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Country | US
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Telephone | 740-355-1161
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | TILLIE ANDRADE
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Credential |
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Telephone | 702-449-9173
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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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