=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306830500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION SURGERY AFFILIATES OF SEGUIN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2005
-----------------------------------------------------
Last Update Date | 07/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 MEDICAL DR
-----------------------------------------------------
City | SEGUIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-401-2800
-----------------------------------------------------
Fax | 830-401-4346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 MEDICAL DR
-----------------------------------------------------
City | SEGUIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-401-2800
-----------------------------------------------------
Fax | 730-401-4346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. TERI K WOLFF
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 830-401-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 008149
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------