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General NPI Number Information
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NPI Number | 1437112455
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Entity Type | Organization
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Legal Business Name | SPACE COAST SURGICAL CENTER LTD
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Dates
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Enumeration Date | 04/10/2006
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Last Update Date | 03/28/2016
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Provider Practice Location Address
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Address Line | 220 N SYKES CREEK PKWY SUITE 101
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-3490
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Country | US
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Telephone | 321-459-0015
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Fax | 321-459-2291
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Provider Business Mailing Address
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Address Line | 220 N SYKES CREEK PKWY SUITE 101
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-3490
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Country | US
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Telephone | 321-459-0015
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Fax | 321-459-2291
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | CYNTHIA A JOHNSON
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Credential |
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Telephone | 321-459-0015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 984
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License Number State | FL
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