=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780163378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTLAKE SURGICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2018
-----------------------------------------------------
Last Update Date | 03/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2007 SHASTA RIDGE DR
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-4697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-444-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2007 SHASTA RIDGE DR
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-4697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-444-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED SURGICAL ASSISTANT
-----------------------------------------------------
Name | TIFFANY BROOKE MORELAND
-----------------------------------------------------
Credential | LSA
-----------------------------------------------------
Telephone | 936-444-7071
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | SA00639
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------