=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467937623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL HEALTHCARE SYSTEM AMBULATORY CARE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2018
-----------------------------------------------------
Last Update Date | 02/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3377 SOUTH STATE ROAD 7 SUITE 200
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33449-8082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-265-3451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3111 STIRLING RD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-6566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-265-3451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT
-----------------------------------------------------
Name | NINA BEAUCHESNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-265-3451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------