=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255486494
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMBULATORY SURGERY CENTER OF BOCA RATON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 04/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 CLINTMOORE ROAD SUITE 300
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-544-5501
-----------------------------------------------------
Fax | 561-544-5528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 CLINTMOORE ROAD SUITE 300
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-544-5501
-----------------------------------------------------
Fax | 561-544-5528
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MANISH GUPTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-544-5501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------