=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255875126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIP SURG ASC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1246 N FM 3083 RD W STE A
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-441-2233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1246 N FM 3083 RD W STE A
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-441-2233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL ADMINISTRATOR
-----------------------------------------------------
Name | MELISSA DAVIDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 936-441-2233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------