=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396131751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEYSTONE SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2015
-----------------------------------------------------
Last Update Date | 08/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10005 SOUTH MAIN ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-5209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-701-8000
-----------------------------------------------------
Fax | 346-701-8001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10005 SOUTH MAIN ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-5209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-701-8000
-----------------------------------------------------
Fax | 346-701-8001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. KENNETH L LE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 832-799-7899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 130229
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------