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General NPI Number Information
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NPI Number | 1619979580
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Entity Type | Organization
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Legal Business Name | PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 1185 DUNLAWTON AVE STE 100
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City | PORT ORANGE
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State | FL
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Zip | 32127-2906
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Country | US
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Telephone | 386-777-7151
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Fax | 386-231-6545
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Provider Business Mailing Address
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Address Line | 1185 DUNLAWTON AVE SUITE 100
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City | PORT ORANGE
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State | FL
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Zip | 32127-2905
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Country | US
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Telephone | 386-777-7151
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Fax | 386-231-6545
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Authorized Official
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Title or Position | CFO
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Name | CORY DOMAYER
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Credential |
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Telephone | 386-843-3420
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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 | 1227
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License Number State | FL
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