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General NPI Number Information
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NPI Number | 1609940899
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Entity Type | Organization
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Legal Business Name | 2096 EAST OCEAN BOULEVARD, LC
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 02/02/2012
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Provider Practice Location Address
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Address Line | 2096 SE OCEAN BLVD
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City | STUART
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State | FL
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Zip | 34996-3304
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Country | US
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Telephone | 772-223-0174
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Fax | 772-223-0558
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Provider Business Mailing Address
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Address Line | 2096 SE OCEAN BLVD
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City | STUART
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State | FL
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Zip | 34996-3304
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Country | US
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Telephone | 772-223-0174
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Fax | 772-223-0558
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. BARBARA ANN TIDWELL
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Credential |
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Telephone | 772-223-0174
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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 | 901
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License Number State | FL
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