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General NPI Number Information
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NPI Number | 1457965832
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Entity Type | Organization
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Legal Business Name | LASER AND OUTPATIENT SURGERY CENTER LLC
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Dates
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Enumeration Date | 09/03/2020
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Last Update Date | 12/08/2020
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Provider Practice Location Address
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Address Line | 6925 NW 11TH PL
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City | GAINESVILLE
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State | FL
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Zip | 32605-3101
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Country | US
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Telephone | 352-331-1590
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Fax | 352-331-0995
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Provider Business Mailing Address
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Address Line | 4919 MEMORIAL HWY STE 200
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City | TAMPA
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State | FL
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Zip | 33634-7500
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Country | US
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Telephone | 813-291-7015
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Fax | 813-527-9537
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Authorized Official
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Title or Position | OFFICER AND AUTHORIZED OFFICIAL
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Name | JENNIFER BOYD BALDOCK
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Credential |
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Telephone | 615-234-5900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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